Issue no. 3.

2002

MAGNETOM F L A S H

1st MAGNETOM World Summit Nice, France July 10-12, 2002

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medical

MAGNETOM FLASH 3

Content
Topic 1. MAGNETOM WORLD SUMMIT NICE, FRANCE, JULY 10-12, 2002 Lectures July 11, 2002 ULTRA HIGH-FIELD A New Era with MAGNETOM Trio Comparison of Cardiac MRI at 3T and 1.5T: Preliminary Results MAGNETOM Allegra goes syngo Minimizing SAR for TSE-imaging with Hyperecho-TSE and TRAPS Cognitive Neuroscience Center at the Singapore General Hospital CARDIO VASCULAR Center of Excellence in Cardiovascular Imaging, Australia Cardiac Ambassadors Meeting, New York, June 27-29, 2002 Duke University Cardiac MR Center MR Angiography with Integrated Parallel Acquisition Techniques (iPAT) Contrast Enhanced MR Demonstration of Thoracic Central Veins Assessment of myocardial viability by “Late Enhancement” A New Dimension in Cardiac Viability Diagnosis WOMEN’S HEALTH Clinical MRI of the Breast for Lesion Detection PEDIATRIC IMAGING Fetal MRI: an Overview SPECTROSCOPY Interpretation of proton spectra of brain tumors using INTERPRET 68 66 62 46 50 52 54 56 58 60 28 30 34 38 44 Page 4 8 Topic ORTHOPEDICS MR Imaging of the Knee in Ironman Triathlon Athletes Magnetic Resonance Imaging of The Wrist MR imaging of non-displaced fracture of the humerus TECHNOLOGY CORNER Eight RF Receiver Channels and the Integrated Panoramic Array (IPA™) Top Ten syngo Questions EVENTS Invitation from the Organizational committee to the MAGNETOM World WHOLE BODY MRI The era of whole body MRI MRI SAFETY Safety Considerations for Patients Referred for Cardiovascular MR Procedures OPEN CLASS MAGNETOM Concerto – The economical open MR scanner New features of the MAGNETOM Concerto 97 99 92 86 84 78 82 Page

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The information presented in MAGNETOM® Flash is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Medical Solutions, Inc. to be used for any purpose in that regard.

Editorial Team

Editorial
I wish MAGNETOM World team could meet more often in the glittering French resort of Nice. The Mediterranean sunshine, haute cuisine and fine wines provided the perfect ambiance for our speakers to really excel themselves and more than prove the genuine value of our MAGNETOM World community. This new format for serious talk and equally serious fun is something which has clearly fired the imaginations of everyone within our community. So it’s ‘Au revoir’ to Nice and ‘Bring it on, Miami’, as we whet our appetites for more of the same in Florida in September, 2003. Please contact your local Siemens representative for more exciting details. Our MAGNETOM World working groups are busy. CMR Ambassadors met in New York and engaged in a very fruitful exchange of information with Siemens: we feel confident of seeing the impact of these exchanges in coming years with the development of new products from Siemens. The Pediatric MR Imaging workshop in Erlangen was also a success. It is clear that MR has a lot to offer in this area; developments and expectations in renal imaging and perfusion analysis were particularly interesting. Please take the time to enjoy our community web page, which is now online: www.SiemensMedical.com/MAGNETOM-World Here you will find case reports, images, clinical methods and clinical protocols, meeting information and training opportunities with MAGNETOM users. The protocol exchange on this web-page will run with Phoenix in the future, which will allow you to download image parameters from displayed images and use these parameters in your scanner. I really believe this to be the best way forward in protocol optimization. We are proud as a Siemens MR group to provide the forwardlooking solutions to our customers which leave our competitors struggling to keep up. Today they boast about providing 8 fast channels in MR scanners, even though this is something MAGNETOM systems had introduced in 1997, a full five years before. I believe the same thing is going to happen again: by around 2008 our competitors will have eventually come up with syngo-like solutions and Phoenix online protocol exchange opportunities and get excited about what, to us, is history. What can we do but smile sympathetically at the late-development of our competitors! I sincerely hope you all enjoy using the state of the art MAGNETOM scanners in a partnership which simply leads the field. Enjoy this issue of Flash.

Tony Enright, Ph.D. Asia Pacific Collaboration, Australia

Laurie Fisher, B.S.R.T., R, MR US Installed Base Manager, Malvern, PA

Marion Hellinger, MTRA MR MarketingApplication Training, Erlangen

Daniel Grosu, M.D. US R&D Collaborations, Malvern, PA

Milind Dhamankar, M.D. MR MarketingApplications, Erlangen

Michael Wendt, Ph.D. US R&D Collaborations, Malvern, PA

Dagmar ThomsikSchröpfer, Ph.D. MR Marketing-Products, Erlangen

Helmuth Schultze-Haakh, Ph.D. US R&D Collaborations, Malvern, PA

Peter Kreisler, Ph.D. Collaborations & Applications, Erlangen

Judy Behrens, R.T. (MR) (CT) Adv. Clinical Applications Specialist

Charlie Collins, B.S.R.T. Market Manager (USA), Erlangen

Raya Dubner Design Editor, Malvern, PA

A. Nejat Bengi, M.D. Editor in Chief

Antje Hellwich Design Editor, Erlangen

Achim Riedl Technical Support, Erlangen

We thank Harald Werner and Lawrence Tallentire for their editorial help.

MAGNETOM FLASH 3

1. MAGNETOM World Summit Nice, France, July 10-12, 2002

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MAGNETOM FLASH 3

Get Together July 10, 2002

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MAGNETOM FLASH 3

Lectures July 11, 2002
Dr. Vivian S. Lee New York University, USA
Dr. Lee then discussed living liver donors for transplantation: the right lobe from donors are transplanted to recipients. The livers have to be evaluated in detail for fatty infiltration, arterial anatomy, portal-hepatic veins and biliary ducts. The variants of biliary ducts are important to diagnose. Biliary anatomy using conventional 2D, single shot TSE techniques, is not easy to visualize. A technique developed by NYU - cholangiography with VIBE after Teslascan infusion** – seems to offer an optimal solution. The VIBE sequence is applied 10-15 minutes following Teslascan administration. The isotropic images allow reconstruction in any plane which provides detailed anatomical information (Fig. 4). Moving from anatomy into function, Dr. Lee briefly mentioned renal studies in her clinic. Her renal examination protocol takes less than 30 minutes in total (Fig. 5, you can see the details of this protocol at www.SiemensMedical.com/MAGNETOM-World, under gastrointestinal imaging working group, clinical protocols). Gadolinium is, like inulin or creatinin, a useful marker for kidney function. This can be used for the diagnosis of renovascular disease, evaluating kidney transplant glomerular filtration rate and for split renal function. In renal transplant patients, MR can be used to understand the reason for dysfunction. In renovascular hypertension detection of stenosis is important, though evaluation of perfusion is very helpful in making the diagnosis in difficult cases. The addition of ACE inhibitors** like “Captopril” will also enhance the diagnostic information provided by MR. In renal artery stenosis, GFR (Glomerular filtration rate) should drop after the administration of “ACE inhibitors”. Dr. Lee also expressed her hopes for combining MR Angiography with GFR and renal function studies when these two applications are introduced into routine practice. Renal transplant donors have to be evaluated carefully. The renal arteries have to be normal and accessory renal arteries supplying the kidney have to be shown thoroughly clearly (Fig. 6). The arterial – venous phase has to be seen (Fig. 7), as does the renal urogram (Fig. 8) showing the collecting system and ureters. Today, thanks to state of the art systems, functional information can also be provided with new sequences which scan 32 slices in three seconds, enabling 3D MR renography. The important question is whether tubular pathologies can be seen and differentiated from acute rejection. ATN (Acute Tubuler Necrosts): normal peak cortex & medulla, delayed renal pelvis peak enhancement. Acute rejection: all three peaks delayed. This evaluation requires visualization of cortex and medulla and being able to see their enhancement patterns. Automatic segmentation for kidneys differentiating the cortex, medulla and collecting system will be an important step in establishing MR, the modality of choice for applications like GFR quantification with MR, the visualization of enhancement patterns of cortex, medulla for diagnosis of ATN or rejection in renal transplant cases (Fig.9).

Dr. Lee started her talk by thanking Siemens for keeping the meeting short enough to allow MAGNETOM World members the time to enjoy the pleasures on offer in Nice (Fig. 1). The general theme of the talk was body MR imaging, moving from the subject of anatomy to that of function. VIBE (Volume interpolated breathhold examination) was the first topic. This technique allows 2D imaging in the abdomen to be replaced by 3D imaging, thanks to collaboration between Siemens scientists and NYU. VIBE is basically a Turbo MRA sequence with lower flip angle and intermittent fat suppression (Fig.2). As the images are isotropic, it allows multiprojection which helps diagnose lesions difficult to judge with axial examination, such as liver lesions at the dome of the liver. VIBE should be combined with proper timing schemes in order to see the arterial phase – something which is very important – using either a test bolus or care bolus for this timing. Vascular anatomy can also be seen in detail with this technique without extra contrast material. It is simply a case of retrieving the MIP or Volume rendered images from the clinical images created (Fig. 3). Dr. Lee also gave a couple of examples from her works using VIBE at NYU.

** Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safety or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries where Siemens has systems. Siemens makes no claims as to the patient/staff safety, MR compatibility, or clinical capability of any of the non-Siemens devices included in the article. Before introduction of any device into the MR suite, the device should be inspected by qualified hospital personnel, and the non-magnetic properties of the device and its clinical operation in the magnetic field verified before it is used in a procedure. Use of these devices for animal or human procedures must comply with any applicable Governmental or local hospital safety and animal/ human studies committee’s requirements.

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Figure 1

Figure 2 3D VIBE TR/TE/flip: 4.2/1.8/12° 1.5 - 2.5 mm thick slices 80 - 128 slices to cover liver (axial) Pixel size 1.6 x 2 x 2 mm Near isotropic pixel size MPR/MIP reconstructions Acquisition times < 25 sec Axial T1 GRE (BH) - Dual echo in-phase, opposed phase Coronal HASTE (BH) Pre-contrast 3D-GRE (BH) Timing examination Contrast-enhanced 3D-GRE: 20 ml - Arterial phase 30 min - Venous phase exam! (delay 45 – 60 sec) Repeat axial T1 GRE (in-phase) Figure 5 Renal MRI Protocol

Figure 3 Volume Rendered VIBE images

Figure 4 VIBE MR Cholangiography. Right lateral duct off left hepatic duct

Figure 6 Accesory renal arteries shown with renal MRA

Figure 9 Segmentation of the kidney

Figure 7 Visualization of renal veins in transplant donors

Figure 8 Later phases of renal MR examination show the collecting system and ureters 9

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MAGNETOM FLASH 3

Dr. Thomas Lauenstein Essen University, Germany

Cerebrovascular MRI
Stroke is the third most common disease in the western world. Neuro protocols at Essen for screeening cerebrovascular diseases contain T1w SE, T2-w TSE, FLAIR, TOF and no i.v. contrast. The examination takes about 10 minutes. This examination allows to obtain of morphological information; detecting unknown pathologies and, to a certain degree, information can be provided regarding possible cerebrovascular diseases.

MR Colonography
90 % of colon cancers develop from polyps. The detection and early removal of these polyps will stop the progression of disease. Transition time from a polyp to cancer is long – between 5 and 10 years – which makes this tool ideal for screening. The cancer risk depends on the size of the polyp. Essen University radiologists use a technique called “Dark Lumen Imaging” which involves the scanning of the whole colon after intrarectal administration of water and i.v. Gadolinium (Fig. 3). The scan starts after 75 seconds, which seems to be the optimal timing for the enhancement of polyps. MR screening detected many unknown lesions which affected treatment and follow-up of the screening population (Fig. 4).

Dr. Lauenstein’s topic was “MRI based multi-organ screening”. The question he asked at the beginning of his talk was “Why MRI instead of other modalities?” The answer he gave for the question was very convincing: there is no radiation involved, it is non-invasive, there are no known side effects of MR and, in his experience, its accuracy is greater than with other modalities due to improved contrast resolution and flexibility innate in MR.

Whole Body MR Angiography
Whole Body MRA (Fig. 1): Arterial disease is a systemic disease, which is why showing the whole arterial tree in patients with risk provides important information that might affect the lifestyle of patients. CP Body Array Coil and “Angiosurf**” provide excellent results in this examination (Fig. 2). Total acquisition time is 72 seconds. The entire examination time is 15 minutes.

Combining multiple exams in one protocol
Certain cerebrovascular and cardiovascular diseases and cancers like colorectal cancer are treatable and have less consequences when diagnosed at an early stage. Essen University uses a 1.5 Tesla system, Sonata, and ultrafast sequences to do whole body screening. It also uses a system called “Angiosurf**” for moving patients in the MR scanner in such a way that wholebody scanning is made possible.

Cardiovascular disease
The Essen group uses TrueFISP cine, short axis and long axis imaging to evaluate the cardiac function. They also use TurboFLASH with a contrast agent*** to see the late enhancement which provides information about infarcted tissue, and which in some cases might reveal silent infarcts. The HASTE sequence is being used to evaluate the lung.

** Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safety or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries where Siemens has systems. Siemens makes no claims as to the patient/staff safety, MR compatibility, or clinical capability of any of the non-Siemens devices included in the article. Before introduction of any device into the MR suite, the device should be inspected by qualified hospital personnel, and the non-magnetic properties of the device and its clinical operation in the magnetic field verified before it is used in a procedure. Use of these devices for animal or human procedures must comply with any applicable Governmental or local hospital safety and animal/ human studies committee’s requirements. *** “This information concerns a use of contrast media that has not been approved by the Food and Drug Administration”. (21 CFR 99.103 (a) (1) (i).

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Figure 1 Whole Body MRA covering from carotids to foot vessels

Figure 3 Dark Lumen MR Colonography and virtual colonoscopy

Figure 2 Visualization of distal vessels with array coils in whole body MRA

Figure 4 Visualization of sigmoid polyp with dark lumen MR Colonography and virtual colonoscopy

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MAGNETOM FLASH 3

Dr. Bart Op De Beeck Antwerp University, Belgium

Dr. Op De Beeck started his talk by mentioning the physical limits reached by MR systems today and the new solutions on offer for faster imaging techniques which include, of course, iPAT, the parallel imaging solution from Siemens with both mSENSE and GRAPPA techniques.

The physical principles of GRAPPA and mSENSE and hardware advantages with new coils – especially 6 channel Body Array* – were emphasized. The benefits of having both GRAPPA and mSENSE were summarized in this way: different applications need different algorithms for optimal solutions and Siemens was the only company which could provide this (see Flash 2/2002 for more details). The further advantage of autocalibration in decreasing examination times in comparison to separate pre-scan was also mentioned.

He summarized his view of iPAT imaging by answering a couple of important questions: s Is the image quality sufficient for clinical use? - Yes, especially for Flash and HASTE. s Which clinical applications are improved by employing PAT? - shorter breath hold abdominal studies with fewer artifacts; - increased temporal resolution in dynamic contrast studies; - greater coverage or higher spatial resolution in the same time, - fewer motion artifacts and reduced blurring

Figure 1 Better delineation of lesions and good corticomedullary differentiation with iPAT images. HASTE coronal images, high resolution iPAT image (Right), conventional (left) same acquisition time.

Figure 2 iPAT HASTE in diagnosis of multiple endocrine neoplasms

* “The information about the 6 Channel Array Coil is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S.”

“Clinical implementation of parallel imaging is possible now using existing arrays and receiver systems. Particularly for applications with stringent requirements on imaging speed, parallel imaging can be a useful tool to enhance image quality, to improve imaging efficiency, and in general to overcome the acquisition speed limit in magnetic resonance imaging.”

Figure 3 MR Cholangiography with iPAT in a patient with chronic pancreatitis

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Prof. Dr. Richard Semelka University of North Carolina, USA

Dr. Richard Semelka’s talk offered an overall view of MR in the area of body imaging. He started his talk by stressing how straightforward protocols would help MR become standardized like CT. He stressed that a consistent good image quality will help consistent disease display. UNC protocols are divided into cooperative and noncooperative protocols. The future directions were defined as breathing independent sequences. Due to short bore MR systems and faster systems with advanced gradients, the number of non-cooperative patients has decreased. Most non-cooperative patients are said to be pediatric patients. FLASH, fat suppressed FLASH and out-of-phase FLASH are the sequences of choice for T1 weighted imaging. He expressed his happiness with 3D VIBE sequences that he received using the latest software (Fig. 1). The T2 weighted sequences he uses are basically HASTE and TurboSTIR (Fig. 2). Dr. Semelka’s hopes for the new iPAT technique were summarized with the following words: “I hope iPAT will take all good sequences and make image acquisition time shorter and make them essentially breathingindependent”. HASTE is the best in all CT & MR approaches where there is the risk of metallic implants. A good example of this would be patients with hip replacement. According to Dr. Semelka, the most import sequence in MR is immediate post contrast FLASH or 3D VIBE. Dr. Semelka also touched on the topic of “Contrast agents” in MR and he offered the opinion that agents that combine early non-specific extracellular, and late hepatocyte selective properties will be the contrast medium of choice in the future.

Figure 1 3D VIBE image results

Figure 2 HASTE image showing intussusception

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MAGNETOM FLASH 3

Prof. Dr. Dudley Pennell Royal Brompton Hospital, London, UK

Dr. Pennell’s talk focused on the market for cardiac MR and the future directions it would take. He began by mentioning a depressing statistics saying: “Half of deaths are caused by cardiovascular diseases, that is either you or the person sitting next to you. You can take your choice”. He added that even though advanced medical care and preventive strategies were reducing the number of coronary disease cases per thousand population, in total the number of people with this ailment showed a tendency to increase due to the increased number of people reaching older ages.

Echocardiography was defined as the right choice for left ventricular function analysis: MR comes into play as soon as there is a myocardial infarction and there are changes in the shape of the heart. In this case, the choice could be 3D echo or well established MR. A series of cines are obtained from the base of the heart to the apex where the difference between end-systole and end-diastole is measured. From this data, ejection fraction and mass can be calculated (Fig. 1). An automized reliable technique was also speculated to have an impact on drug research. Turning then to specific diseases, Professor Pennell began by referring to hypertension. Left ventricular hypertrophy causes an increased risk of death in hypertensive patients. Measuring the mass of the myocardium in diagnosis of hypertrophy is a key step which can be done today with the available MR technology and software. Giving more statistical data, he said that 13,000,000 echos had been performed in the US last year. 10 % of echos do not contain sufficient information. This market can be captured by MR. Stress echo was also another procedure that could also be replaced by MR. Realtime MR is reliable method today which could be used when echo fails which is 15-20 % of the time (Fig. 2). TrueFISP was defined as the sequence of choice. Perfusion*** parametric maps created by MR generally match thallium abnormalities. Resolution with MR is 10 times better, subendocardial abnormality versus transmural perfusion abnormality can be differentiated by using MR (Fig.3a, Fig. 3b). The cases when MR perfusion can be used are: when SPECT fails, when there are attenuation artifacts with SPECT, where breast artifacts

in women occur and when there are attenuation artifacts in men. The timeline for clinical applicability of MR replacing SPECT seems to suggest this will happen in the very near future. Viability technique with MR received special attention during the talk. This technique in the case of 50 % or less enhancement of the myocardium shows an indication for surgery where one can assume that these areas will improve. Professor Pennell’s personal view was that this technique could be applied in 100% of all myocardial infarction cases (Fig. 4). Coronary anomalies was another area where cardiac MR could have an impact. Professor Pennell said that robust coronary imaging in clinical practice was not something that seemed possible in the near future, although the influence of 3 Tesla should not be ruled out. The obstacles facing Cardiac MR imaging lie with the fact that there is not enough experience out in the field and most centers are uncomfortable performing this examination. Professor Pennell finished his speech by saying that there is a huge potential in the market and that education is the most important issue in bringing cardiac MR into routine practice.

*** “This information concerns a use of contrast media that has not been approved by the Food and Drug Administration”. (21 CFR 99.103 (a) (1) (i).

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ED

ES

Aortic regurgitation LV LV LV LV LV End Diastole End Systole Stroke Volume Ejection fraction Mass 219 ml 107 ml 112 ml 51% 243 g 125 g/m2 103-161 28-72 49-113 47-75 96 +/-15

LV Mass index

Figure 1a

Figure 1b 3D Assessment of Ventricular Function

Rest

Stress

Figure 3a

Figure 2 Real-time: CMR vs Echo

Thallium Rest

Time to peak Peak intensity

Slope

Stress

Figure 3b Fig. 3a/3b: Myocardial Perfusion – Parametric Maps

Figure 4 Viability technique showing transmural MI 15

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MAGNETOM FLASH 3

Dr. Joerg Barkhausen Essen University, Germany

Dr. Barkhausen expressed his views regarding the future of vascular MRI. Standard examinations today cover a large spectrum of applications, including cerebral MRA, carotid MRA, thoracic aorta MRA, pulmonary artery MRA, imaging of the abdominal aorta and branches and applications under development such as peripheral MRA. Run-off vessels can be examined with dedicated array coils and Essen University has been performing whole body MR Angiography for screening purposes: this is a new application in the field of MR being developed by Essen University radiologists. The tendency he sees in overall MR Angiography is more in the direction of 4D imaging, i.e. anatomical imaging with temporal information added. Dr. Barkhausen also mentioned the different techniques in coronary angiography using navigators and breath-hold techniques. As a new idea being tried by centers throughout the world, he said that TrueFISP could also be used for MR Coronary Angiography. His overall summary of coronary angiography was that contrast enhanced MR angiography with breath-hold is a better technique than techniques requiring navigators and long examination times.

Dr. Barkhausen then talked about vascular wall imaging with dedicated coils and contrast material. Essen is in close collaboration with the Siemens MR Unit in developing new methods in vascular therapy with MR, and Dr. Barkhausen demonstrated the special catheters dedicated to MR vascular imaging as well as the real time image fusion technique that are being used by him in interventional vascular MR imaging. At the end of his talk, Dr. Barkhausen concluded that today MR is the diagnostic choice in almost all vascular diseases.

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MAGNETOM FLASH 3

Before chemotherapy

Prof. Dr. Albert van Rossum Free University Amsterdam, The Netherlands

Professor van Rossum gave a talk about the clinical indications of cardiac MR imaging, dividing the indications into two groups:

1. Primary Indications for Cardiac MR
s Great vessel disease (aneurysm, dissection, coarctation) s Complex congenital heart disease (including RV function) s Pericardial disease (thickness, cysts, effusion) s Tumors s Cardiomyopathies (ARVD, HOCM) s Anomalous origin of coronary arteries / bypass graft patency s Myocardial viability (scar tissue)*** Figure 1 Pericardial Disease Monitoring tumor reduction (angiosarcoma) After chemotherapy

2. Secondary Indications (complementary to echo)
s Global and regional LV function quantification: Volumes, mass, wall thickness, wall thickening s Valvular heart disease: Follow-up of volumes, quantification of regurgitation and shunts s Detection of ischemia (wall motion): Stress-induced wall motion abnormalities (dobutamine high dose), contractile reserve (dobutamine low dose)

*** “This information concerns a use of contrast media that has not been approved by the Food and Drug Administration”. (21 CFR 99.103 (a) (1) (i).

Figure 5 Hyperenhancement indicates non-viable myocardium. Subendocardial anterior infarct (arrows).

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Figure 3 Delayed contrast enhanced imaging. Single breath-hold image in diastole

Figure 4 Heart Failure excellent myocardial wall / blood pool definition, high resolution, easy and quick evaluation of the heart with TrueFISP.

Figure 2 Right ventricular tumor, metastasis of leiomyosarcoma. Comparison between echo and MR images

Figure 7 FDG PET versus CE MRI

Figure 6 Delayed CE MRI in patients with healed myocardial infarction. In enhancing areas there is focal interstitial fibrosis, where you can also observe regional dysfunction.

Figure 8 Quantification of aortic regurgitation. 19

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MAGNETOM FLASH 3

Dr. Ozsarlak Antwerp University, Belgium

s Overall SNR is markedly improved and is on average 45-113 % superior to that obtained with a standard CP volume head coil. s The highest gains in SNR are observed in axial sequences. This presumably reflects the equal contributions of all coil elements. s On sagittal sequences, the gain in SNR is lower (in equal contributions of coil elements). Still, in the deeper parts of the brain (e.g. brainstem) SNR is better than with the CP Head Array Coil. s The high intrinsic SNR of the 8channel Head Array Coil can be used in conjunction with iPAT in order to: - decrease imaging time, - improve spatial resolution (multi-averaging), - or a combination of both.

Dr. Ozsarlak’s talk summarized the wealth of experience in his clinic with Parallel Acquisition techniques and the neuro experiences with syngo MR 2002B Maestro Class Software.

Figure 1 Visualization of intracranial vessels after administration of 20 ml Gadolinium with 8-channel Head Array Coil. Conventional iPAT x2 TA= 2’20” TA= 1’20” iPAT x3 TA= 50”

iPAT and CE Angiography
Dr. Ozsarlak outlined the advantages gained by the 8-channel head coil and iPAT technique in image sharpness, image contrast and visualization of intracranial vessels. Background suppression was found to be same as with CP Head Array Coil. He also expressed his happiness with the water excitation technique which provided better background suppression than other techniques (Fig1, Fig2).

Spine Imaging and iPAT
(Fig. 5, Fig. 6) Dr. Ozsarlak brought a new perspective to spine imaging with his observations that multi-averaging helped decrease artifacts in spine imaging, and provided better image quality than conventional approaches. Of course, in cases where there is need for extremely fast imaging, iPAT can be used to decrease imaging time. Overall, he was in support of GRAPPA technique as it created fewer artifacts in imaging the spine. Figure 5 TSE T2 Ac = 1, FOV = 300 x 300, Matrix = 307x512, SL = 4 mm, GRAPPA

MRI of the Brain
There were also remarkable advantages in imaging of the brain, according to Dr. Ozsarlak's evaluation (Fig. 3, Fig. 4): s The 8-channel Head Array coil provides excellent high-resolution imaging with anatomical coverage of the entire head. s The 8-channel Head Array coil is PAT optimized and allows the use of both SMASH (GRAPPA) and SENSE (mSENSE) type sequences.

STROKE
The results with color-coded maps in stroke imaging were important in evaluating stroke patients as a way of showing tissue at risk (Fig. 7).

Figure 7a 71-y-old male with acute stroke. Diffusion weighted images and ADC maps.

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Figure 2 8-channel Head Array Coil, TOF-we

Figure 3 Axial TSE T2-WI TR 3800 ms, TE 100 ms, recFOV with 512 matrix, TA 45.7 sec with PAT, normalization correction

Figure 4 Decreased distortion artifacts with iPAT. Left image result with 8 channel Head Array Coil and iPAT technique. Right with CP Head Array Coil.

Figure 6 iPAT cervical spine images with multi averaging (right) vs conventional technique(left). Conventional averages = 2 TA = 2’ 42’’ SL = 3 mm; FOV = 280 mm GRAPPA x2 averages = 4 TA = 3’ 30’’ SL = 3 mm; FOV = 280 mm swallowing every 20 sec!

Figure 7b 71-y-old male with acute stroke. Perfusion maps showing mean transit time (MTT)

Figure 7c 71-y-old male with acute stroke. Perfusion maps showing time to peak (TTP).

Figure 7d 71-y-old male with acute stroke. Perfusion maps showing relative cerebral blood volume (rel CBV)

Figure 7e 71-y-old male with acute stroke. Perfusion maps showing relative cerebral blood flow (rel CBF) 21

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MAGNETOM FLASH 3

Evening Event July 11, 2002

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MAGNETOM FLASH 3

1.5 T July 2001

3T January 2002

Dr. Elna-Marie Larsson University Hospital Lund, Sweden

Dr. Larson talked about her experience in neuro MR imaging with 3 Tesla MAGNETOM Allegra system in a clinical setting. The advantages of a 3 Tesla system in general are increased SNR, increased susceptibility which is useful for fMRI and for visualization of iron-containing structures, and increase of chemical shift effect which is useful for MR spectroscopy. She expressed her satisfaction with improved image quality especially in MRA due to increased T1.
SNR increase Increased susceptibility effect Increased SAR/power deposition Increase of chemical shift Longer T1 Increased contrast enhancement Increased flow artifacts + + + + + -

Figure 2 3T = Higher signal

Figure 3 3D CISS images with MAGNETOM Allegra

Figure 4 3D ToF without contrast injection

Figure 5 Higher SNR with MAGNETOM Allegra 3T. Acute stroke patient, 74-year old woman with right-sided hemiparesis.

Figure 1 3T compared with lower field strengths

T2 Turbo FLAIR

DWI

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Dr. A. Gregory Sorensen Massachusetts General Hospital, USA

Dr. Sorensen's talk looked into the future of 3 Tesla and advanced neuro imaging with new diagnostic possibilities that can have an impact in the global burden of disease. In agreement with Dr. Larson, Dr. Sorensen also mentioned the basic advantages of 3 Tesla, including increased SNR and increased BOLD effect. He added that the fMRI community has largely migrated to 3 Tesla. Dr. Sorensen also talked about his experience with MAGNETOM Trio 8channel coils. Increased channels would be another factor helping improve applications that need more signal, such as diffusion tensor imaging and arterial spin labeling.

He also mentioned future applications, such as thalamic parcelation and MR tractography for the diagnosis of diseases with connections between different parts of the brain**. He added that super tensor imaging with hundreds of directions would help in the realization of these future applications. “Computer Aided Diagnosis will play a major role in neuro imaging”, was Dr. Sorensen’s considered view. He showed a couple of examples of his results with automatic segmentation of gray and white matter and also demonstrated the use of “Auto Align technology” which will help in the follow-up of patients at different times. This tool creates a 3D high resolution scout of the patient which registers the slices to be scanned and this allows the software to recognize the patient each time and places the slices in the exact same position in follow-up scans.

Figure 1 DTI can reveal anatomical structures that can not be seen by conventional MRI. The internal thalamic structure (12 different main nuclei) becomes visible in a DTI experiment due to local differences in anisotropic diffusion: All images courtesy of D.Tuch, MGH Boston

Figure 2 Image shows projections from rostral pons into the corona radiata via thalamus (blue fibers). Red fibers are the cerebellar pontine fibers projecting into the middle cerebellar peduncle. Data acquisition was done on a 3T MAGNETOM Allegra with 258 different diffusion gradient directions at a strength of 40mT/m, b-values 20000 s/mm2, TE = 140 ms, gradient pulse length 60 ms. Image courtesy of David Tuch, MGH Boston

** Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safety or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries where Siemens has systems. Siemens makes no claims as to the patient/staff safety, MR compatibility, or clinical capability of any of the non-Siemens devices included in the article. Before introduction of any device into the MR suite, the device should be inspected by qualified hospital personnel, and the non-magnetic properties of the device and its clinical operation in the magnetic field verified before it is used in a procedure. Use of these devices for animal or human procedures must comply with any applicable Governmental or local hospital safety and animal/ human studies committee’s requirements.

Figure 3 Diffusion Tensor Imaging Color Display

Figure 4 CE carotid MR Angiography with 3 Tesla MAGNETOM Trio system 25

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Super Technologists

MAGNETOM World includes a very important group called “Super Technologists”. Mr. Bart Schraa from Erasmus Medical Center, Rotterdam, spoke about an innovative use of Blueberry juice in MR Cholangiography.Blueberry juice serves to suppress the signal from the stomach and intestines in T2 weighted single shot images. This approach allows visualization of the biliary system without any signal superposing from the intestine or stomach. Mr. Mark Lourensz from St. Vincents Hospital, Melbourne talked about general abdominal imaging and provided valuable application tips.

The talks given by the “Super Technologists” enhanced the tremendous success of the MAGNETOM World Summit. After a splendid lunch, Dr. Civaia invited MAGNETOM World members to visit his clinic in Monaco where we were all able to admire the wonderful facilities at his disposal. The whole event was suitably rounded off with a champagne toast to this, and future MAGNETOM World Summits. The future looks great.

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MAGNETOM WORLD SUMMIT NICE

Join us in helping to build excellence in Magnetic Resonance Imaging. s Hear from leading experts worldwide on best practices and clinical trends s Exchange ideas and your knowhow with other MAGNETOM users s Learn advanced techniques and innovative solutions s Enjoy the enticing tropical atmosphere unique to South Beach

We are proud to announce the 2nd MAGNETOM World Summit South Beach, Miami – USA Autumn 2003

For more information please contact Raya Dubner from the MAGNETOM World organizational committee.

Email: Fax:

Raya.Dubner@siemens.com +1 (732) 321-32 87

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A New Era with MAGNETOM Trio
Cécile Mohr, Ph.D. Ultra High-Field Segment Market Manager Siemens AG, Medical Solutions, MR Marketing, Erlangen The MAGNETOM Trio – 3T Unlimited – is attracting more and more users by setting new standards in 3T wholebody imaging. Hardly surprising, since the MAGNETOM Trio features: s SAR-reduction technology, including the hyperecho techniques, which ensure safe 3T patient examination and maximize anatomical coverage*. s Standard 8-fast RF channels, enabling the use of up to 32 LP (Linearly Polarized) coil elements s Diversity of iPAT-compatible local coils**, including 12 element Cervical-Thoracic-Lumbar spine array coil, 8-element neurovascular array coil, 8-element torso/pelvis coil, 8-element head array coil s syngo user interface featuring Inline Technology, reducing postprocessing to a minimum . s Duke University, Radiology Department, Durham, NC, USA s University of Freiburg, Germany s Max Planck Institute, Frankfurt, Germany s Hospital of University of Pennsylvania, Philadelphia, PA, USA s Oregon Health Sciences University, Portland, OR, USA s Georgetown University, Washington D.C., USA s Royal Holloway University of London, Egham, United Kingdom

The MAGNETOM Ultra High-Field community is now composed of 59 MAGNETOM Allegra and Trio sites all around the World, from Japan, Singapore, Turkey, Sweden, .. to the USA!

These are features which have enticed new members to join the MAGNETOM Trio network, and we at Siemens MR division are therefore proud to welcome and introduce: Figure 1 MAGNETOM Trio

* The information about this product is preliminary. The product is under development and is not commercially available in the U.S., and its future availability cannot be ensured.” ** Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safety or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries where Siemens has systems. Siemens makes no claims as to the patient/staff safety, MR compatibility, or clinical capability of any of the non-Siemens devices included in the article. Before introduction of any device into the MR suite, the device should be inspected by qualified hospital personnel, and the non-magnetic properties of the device and its clinical operation in the magnetic field verified before it is used in a procedure. Use of these devices for animal or human procedures must comply with any applicable Governmental or local hospital safety and animal/ human studies committee’s requirements.

Figure 2 iPAT at 3T of the lumbar spine – TSE with 12-channel CTL spine array coil

TSE, GRAPPA TR 5500ms, TE 142ms FOV 300 mm x 300 mm, 512 Matrix, SL 4 mm Conventional TA: 3:28 min with PAT x2 TA: 1:50 min with PAT x3 TA: 1:17 min

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Figure 3 iPAT images of the abdomen with MAGNETOM Trio – FLASH 2D with fatsat 8-channel abdominal array coil

FLASH 2D fatsat, GRAPPA FoV 300x 400, Matrix 256 Conventional, TA: 20 s with PAT factor 2, TA: 11s

Figure 4 3T images of the heart with iPAT – cine TrueFISP, 8-channel cardiac array

Conventional TA 22 sec

with PAT factor 2 TA 12 sec

with PAT factor 3 TA 7 sec

Figure 5 Inline Technology on the new syngo user interface Automatic MIP calculations

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Comparison of Cardiac MRI at 3T and 1.5T: Preliminary Results
Denise Hinton, Ph.D. Lawrence Wald, Ph.D. Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA John Pitts, R.T.R. (MR) John Kirsch, Ph.D. Franz Schmitt, Ph.D. Siemens Medical Solutions USA, Malvern, PA

Introduction
Cardiovascular MRI is an application that places extreme demands on sensitivity, spatial resolution, and temporal resolution. As the number of ultra high-field (>1.5T) whole body systems is increasing, the need arises to evaluate the performance of these systems for non-neuro applications. The signal-to-noise advantages of higher magnetic field have been established for cardiac imaging [1]. However, issues of B0 homogeneity, RF tissue interaction [2], and the quality of the ECG signal can potentially reduce the gains offered by a higher magnetic field. We present here initial comparisons between 1.5T (MAGNETOM Sonata) and 3.0T (MAGNETOM Trio) whole body systems equipped with identical state of the art gradient sets (40 mT/m maximum, and 200 mT/m/s slew rate) and with similarly designed body coils. The goals of this study

were to compare the signal-to-noise (SNR) and contrast-to-noise (CNR) ratios for matched studies conducted at both field strengths, and to evaluate the effects of higher SAR (Specific Absorption Rate) at 3 Tesla.

Results and Discussion
1. Signal-to-Noise Ratio Comparison Figure 1 shows short axis bright blood cardiac images obtained on the same 74 year old male volunteer. The images compared are from slice planes located within 1 cm. The acquisition sequence is a breath-hold cine TrueFISP in which 19 images are obtained over the cardiac cycle with identical spatial resolution, TR, TE and 40 degree flip angle. The images were acquired with the body coil in transmit-receive mode and a phased array receiver coil at both field strengths [Fig. 1]. From a region of interest (ROI) analysis of these data

Figure 1 Short Axis cine TrueFISP images 74 year old healthy male volunteer. Breath-held and ECG triggered. Body coil transmit, phased array receiver coil Temporal Resolution = 19 phases over cardiac cycle TE = 1.6 ms, TR = 47 ms, Flip Angle = 40°, FOV = 28 cm x 34 cm, Matrix 162 x 256, 5 mm slice thickness. Both SNR and CNR increase at 3.0T under identical imaging conditions.

1.5 T
Systole

3.0 T

Diastole

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Figure 2 Quantitative Cardiac Evaluation at 3T (noise value taken from background), SNR increases in the myocardium of up to approximately 80%, and 50% increase in CNR between ventricular blood and myocardium, have been observed at 3T. We have measured with this study an SNR gain of up to a factor of 1.8 at 3T, which approaches the factor of 2 predicted for the SNR dependence on the magnet flux B0. Furthermore, in general, bright blood techniques at 3T have improved tissue-blood CNR compared to1.5T acquisitions under similar conditions. 2. Potential for 3T Cardiac Quantitative Evaluation The anterior and posterior thoracic components of a prototype 8 channel array coil (USA Instruments*) designed originally for head-neck angiography provided sufficient coverage of the cardiac anatomy. Cardiac images obtained using the array coil are shown in Figure 2. All major views, including short axis, four-chamber, and long axis are displayed in the panels of the Siemens quantitative cardiac evaluation software (Argus). The excellent image quality and high blood – tissue CNR makes these data suitable for image processing to obtain quantitative measures of ventricular volume, myocardial mass, ejection fraction, etc. Cine TrueFISP images obtained on a 74-year-old male volunteer with known coronary artery disease. The two large panels display 4-chamber (left) and short axis (right) views. Long axis images are shown in the bottom panel.

* Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safety or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries where Siemens has systems. Siemens makes no claims as to the patient/staff safety, MR compatibility, or clinical capability of any of the non-Siemens devices included in the article. Before introduction of any device into the MR suite, the device should be inspected by qualified hospital personnel, and the non-magnetic properties of the device and its clinical operation in the magnetic field verified before it is used in a procedure. Use of these devices for animal or human procedures must comply with any applicable Governmental or local hospital safety and animal/ human studies committee’s requirements.

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3T

1.5T

Particularly striking in these data compared to 1.5T is the improvement in anatomical detail (spatial resolution). For example, when the images of the 4-chamber view are displayed in cine mode, the motion of the chordae tendinae attached to the papillary muscle is well visualized. This is not readily observed at 1.5T.

3. SAR Issues Figure 3 displays a comparison of short axis cine images obtained on the volunteer shown in Figure 2 taken during systole (top panel) and end diastole (lower panel).

At 1.5T, flip angles typically above 50 degrees are needed (for the cine TrueFISP) to obtain high signal for the ventricular blood while minimizing in-flow artifacts and generating myocardial-blood pool CNR above 30. The concern at 3T for cardiac cine TrueFISP imaging is the SAR and achievable flip angle. SAR at 3T limits the flip angle to a maximum of 36 degrees for this subject (with pulse sequence parameters identical to those used at 1.5T), however, image quality and CNR are not significantly reduced. Modifications of RF pulse excitation profiles at 3T will be implemented that will reduce the SAR while allowing for higher flip angles, therefore generating cardiac images with higher overall SNR and CNR.

Figure 3 Short Axis cine True FISP images, both have CNR > 30. SAR limits 3T flip angle to less than 40 degrees, but image CNR remains comparable to 1.5T obtained with flip angle of 50 degrees.

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The feasibility of “dark blood” imaging at 3T is demonstrated in Figure 4. SAR issues are not encountered with this double-inversion prepared fast spin echo image obtained in one breathhold. Fat-suppressed images are shown on the right panel. The excellent resolution of the mitral (left atrioventricular) valve (circle) again demonstrates the SNR gain and high anatomical detail achievable at 3T.

Conclusion
We have demonstrated robust overall gains in SNR at 3T for cardiovascular MRI. Although SAR is an issue at 3T, CNR above 30 for ventricular blood and myocardium is achievable at 3T without any loss in cine temporal resolution. EKG gating and magnetic field homogeneity were not found to be major issues for these 3T studies. The whole body coil transmitter on the MAGNETOM Trio scanner has excellent homogeneity and efficiency, and no SAR issues were encountered with double IR, fat-suppressed, fast spin echo sequences. Phased array coils are critical for achieving maximal SNR gains. Fully equipped whole body 3T MRI scanners have excellent potential for meeting the demands for sensitivity and spatial resolution posed by cardiovascular imaging.

Figure 4 “Dark blood” fast spin echo images of 4-chamber view. Images on right with fat suppression; note resolution of left A-V valve.

References
[ 1 ] Wen H, Dension TJ, Singerman RW, Balaban RS. The intrinsic signal-to-noise ratio in human cardiac imaging at 1.5, 3 and 4 T. J Magn Reson 1997; 125: 65-71. [ 2 ] Roeschmann P. Radiofrequency penetration and absorption in the human body: limitations to high-field whole-body nuclear magnetic resonance imaging. Med Phys 1986; 14: 922-931.

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MAGNETOM Allegra Goes syngo
Cécile Mohr, Ph.D. Ultra High-Field Segment Market Manager MR Division, Siemens AG Medical Solutions, Erlangen Germany

The MAGNETOM Allegra, the only 3T dedicated MR brain scanner, was upgraded to syngo MR in the clinical setting of the Neuroradiology Department of Lund University in Sweden. The 3T MR scanner now runs the latest syngo features, such as Inline Technology, and the Lund group is delighted with these Allegra upgrades. The population scanned on the machine with high-resolution morphological images is composed of patients with tumors, epilepsy, and vascular disease. The short bore of the Allegra magnet (1.25 m) also allows scanning of children from the age or 4-5 years without sedation or anesthesia.

Functional MRI using well-established motor, sensory and language tasks is used to map the brain before surgical removal of tumors. fMRI is then also used post-surgery to ensure that vital functions are not compromised by the surgical operation. The motor task consists of finger-tapping, the sensory task of stimulation of the palm of the patient with a brush or sponge. The sensory stimulation is facilitated by easy access to the patient’s hand due to the short bore of the magnet (only 1.25 m). The language tasks include silent word generation and silent rhyming. In addition, studies of perfusion and diffusion imaging in the brain are combined to assess stroke patients. MR-angiography studies, and especially Time-of-Flight, have excellent quality with improved visualization of small vessels, thanks to the 3T field strength of the MAGNETOM Allegra. MR spectroscopy will be used to assess possible metabolic alterations in patients with intracranial tumors and metabolic disease.

Figure 1 The Radiology Department of Lund University is a multidisciplinary group composed of physicists working closely with radiographers and radiologists. From left to right: Siemens Applications Specialist Gudrun Graf, Physicist Sara Brockstedt, Radiologist Elna Marie Larsson and Radiographer Titti Owman.

Figure 2 Scanning at the syngo MR console in Lund.

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Figure 3 The Radiology Department at the University of Lund, Sweden, host of the first MAGNETOM Allegra running under syngo.

Figure 4a Contrast Enhanced MRA of intracranial vessels. TR: 40 ms TE: 3.5 ms Flash 3D we. FOV: 200 x 200, Matrix: 269 x 512

Figure 4b Left 100 % SAR, right %28 SAR (TSE image with Hyperechoes)

Figure 4c CSI spectroscopy. Resolution 11x11x15 mm3, 6 averages, TE / TR = 20 / 1500 ms, k-space weighted sampling, acquisition time 9 min 21 sec

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MAGNETOM FLASH 3

The MAGNETOM UHF Community

Introduced in 1999, the MAGNETOM Allegra is the fastest 3T machine in the MR industry, featuring gradients with 40 mT/m maximum amplitude per axis (or 69 mT/m effective) and, more importantly, a slew rate of 400 mT/m/ms, equivalent to a rise time of 100 microsecond. This rise time allows fast imaging techniques in an unparalleled way, the key to techniques such as echo-planar imaging. In addition, the MAGNETOM Allegra has been made extremely compact (only 1.25 m long) to ease siting. For these reasons, the Allegra has been the choice of radiologists and basic science researchers, performing functional MRI and advanced brain MR techniques. More than 26 sites use the Allegra world-wide, including Japan and Turkey.

Europe 6 13

USA Continuing until December 2002, an ambitious world-wide upgrade program has been launched by Customer Service. All world-wide MAGNETOM Allegra will be upgraded to syngo. In addition, new options will soon be released, including the ability to image with integrated Parallel Acquisition Techniques (iPAT) – SENSE and SMASH-based techniques for faster and better acquisitions. 18 13

Ralf Ladebeck, Project Manager MAGNETOM Allegra and Trio “We are coordinating a world-wide team of highly technical skilled people. They will allow the transition from the older N3.5 software platform to syngo for all our MAGNETOM Allegra customers. We are excited to bring all the new syngo features to the customers, which will help them expand their applications as well as streamline their workflow.” 36

MAGNETOM Allegra MAGNETOM Trio

ULTRA HIGH-FIELD

Japan 2 2

SE-Asia 1 2

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Minimizing SAR for TSE-imaging with Hyperecho*-TSE and TRAPS
Juergen Hennig Ph.D. Matthias Weigel Ph.D. Klaus Scheffler Ph.D. Radiol. Klinik, University Freiburg, Germany As an example, let us consider a TSEsequence with 10 ms echo spacing (ESP), 2 ms pulse duration and 8 ms acquisition time. Reducing the rfpower of such a sequence by a factor of 2, by reducing the refocusing flip angles to ~125°, will reduce the signal intensity to about 80-90 % of a fully refocused sequence, depending on the degree of sophistication for dealing with reduced flip angles. (Under Numaris 4 the (90°+ /2)variant [2] is implemented, which yields about 90 %). The same SARreduction can be achieved by increasing the pulse duration to 4 ms. The concordant reduction in the acquisition time from 8 to 6 ms will lead to an increase in the bandwidth by a factor of 4/3 and therefore to a reduction in SNR to 86 %, which is roughly in the same range. Although this loss may not be appreciated, it certainly looks tolerable. The situation changes when the echo spacing is further reduced. At ESP = 6 ms with 3 ms acquisition time, prolongation of the pulse duration by 2 ms will shorten the acquisition time to 1 ms, leading to a loss in SNR by a factor of √3, which is clearly not tolerable. Therefore, for these “high-duty” applications, the flip angle reduction may be the only option. Even worse, very short echo spacings will pose even more severe SAR limits. Due to the increased number of pulses, a reduction by a factor of 2 may not be sufficient and the penalties in SNR will become increasingly severe. These problems have led to the situation that TSE, as one of the most desirable sequences for high field MR, has been somewhat less useful at 3 Tesla and more. Really nice images can be demonstrated, but these are often taken with reducedvolume coverage and/or at long echo spacings reminiscent of the early 90s, before the introduction of fast gradient systems.

Is Hyperecho the solution?
This situation has quite significantly changed with the introduction of the hyperecho-mechanism last year [3]. By making use of symmetry relations in the spin behavior with respect to the signal evolution caused by rfpulses and gradients, it could be shown that the full 100 % spin echo signal can be recovered, even after a train of refocusing pulses with very low flip angle. The hyperecho mechanism is a generic new mechanism for signal formation, which can be used in numerous applications. Applied to TSE-imaging, it allows to reduce the rf-power by a factor of 2.5-4 and more without any loss in signal intensity by making use of the fact, that the overall signal-to-noise of images is determined by the signals around the center of k-space. Placing the hyperecho into the data encoding for the k-space center will thus lead to high SNR even though data at the edges of k-space may be somewhat reduced. Fig. 1 shows the flip angles and signal intensities of such a hyperecho TSE implementation. The initial gradual reduction of flip angles is necessary to avoid fluctuations of the echo amplitude, which would occur if constant flip angles were used [4] [5]. The total rf-power of this sequence is only 28 % of that of a fully refocused sequence. As shown in Fig.1b, the resulting signal intensity for brain parenchyma (T1 = 800 ms, T2 = 60 ms) at TE eff = 72 ms is even higher than that of a fullyrefocused sequence due to the contributions of stimulated echoes to the hyperecho. The resulting apparent reduction in the effective echo time can be used to further increase the echo train length at still moderate T2-contrast. Depending on the actual flip angles used, the T2-contrast of hyperecho images can be shown to

TSE (RARE,FSE...)-sequences are currently the most widely used MRtechniques for T2-weigthed diagnosis and an indispensable tool especially for examinations of various pathologies of the CNS [1]. The widespread use of these techniques is primarily due to the very robust and reliable T2-contrast based on the signal generation mechanism by spin echo refocusing.

3T Imaging
In the recent past, 3T-systems have been introduced not only for neuroscientific research with BOLD-based fMRI, but also with the specific purpose of routine clinical diagnosis. With the increasing susceptibility problems and inhomogeneity effects at higher fields, spin-echo refocusing seems to be particularly well suited for high field MR. Although such implementations have been successfully demonstrated even at 8T, the routine use of conventional TSE or HASTE at 3T and beyond is severely hampered by the high rf-power required by long echotrains with 180°-refocusing pulses. In practice, this leads to severe limitations in the number of slices to be acquired at a given TR. A number of means have been introduced to deal with this problem. A flowchart of the various options is shown in diagram 1. The bottom line shows that no matter which option is chosen, some compromise has to be made in terms of SNR/acquisition time/volume coverage/image quality. 38

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180 160 140 120 100 80 60 40 20 Fig. 1a 0 0 20 40 60 80 100 te 120

Figure 1a Refocusing flip angles vs. echo time te along the echotrain of a hyperecho sequence with ETL=15, ESP = 8 ms, TEeff = 72 ms. Figure 1b calculated signal intensities for brain parenchyma (T1 = 800 ms, T2 = 60 ms) for the hyperecho sequence according to Fig. 1a (red) compared to a conventional TSE-sequence with 180° refocusing flip angles.

I (a.u.)

1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1

Fig. 1b

0

0

20

40

60 TEeff

80

100

te 120

* The information about this product is preliminary. The product is under development and is not commercially available in the U.S., and its future availability cannot be ensured.

Figure 2 Hyperecho TSE images acquired with the parameters from Fig.1 at 1.5 T compared to conventional TSE (a). The excellent image quality of the hyperecho TSE-sequence (c) is demonstrated, whereas a reduction of the refocusing flip angle will lead to a severe signal loss (b).

TSE 180°

TSE 60°

HyperTSE 60°

Figure 2a

Figure 2b

Figure 2c

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Figure 3 Conventional TSE-images (left) vs. hyperecho TSE images (right) acquired at 3T (MAGNETOM Trio): in plane resolution 0.4 x 0.4 mm2, slice thickness 2 mm, TE/TR = 109/5000 ms, ETL 27, matrix 512 x 512. With the longer echo train, SAR is even further reduced to 28 %.

180 160 140 120 100 80 60 40 20 Fig. 4a 0 0 50 100 150 200 te 250

Figure 4a Refocusing flip angles vs. echo time (te) along the echotrain of a TRAPS sequence with ETL = 27, ESP = 9 ms, TEeff = 72 ms. Figure 4b Calculated signal intensities for brain parenchyma (T1 = 800 ms, T2 = 60 ms) for this TRAPS sequence (red) compared to a conventional TSE-sequence with 180° refocusing flip angles.

I (a.u.)

1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1

Fig. 4b

0

0

50

100

150

200

te 250

Figure 5 High resolution coronal TRAPS-TSE image acquired at 3T (MAGNETOM Trio). 40

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be equivalent to that in a conventional sequence at an echo time, which is shorter by 20-40 %. Figure 6 Multislice applications with Hyperecho. Sequence used is HASTE. Resulting images shown in Figs. 2 and 3 demonstrate the excellent image quality and show the dramatic improvement compared to a sequence with low flip angles.

TRAPS
As a somewhat complementary way to save rf power without any of the compromises of the conventional approaches, we have recently introduced the TRAPS-sequence (Transition between Pseudo-steady States) [6]. The physics of signal formation How to reduce SAR in TSE-sequences: Conventional approaches

1. increase TR decrease # of slices

2. increase the pulse duration

3. reduce refocusing flip angles

4. use simple pulses: Gauss, rectangular

increase the echo spacing

increase the acquisition bandwidth

reduced imaging efficiency (no breathhold T2) and/or bad volume coverage Diagram 1

at constant duration of the echotrain: reduced ETL, therefore longer acquisition time

at constant ETL: reduced image quality, less slices per TR

reduced SNR

poor slice definition, reduced SNR per mm SLTH, increased gap width

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in TRAPS is quite different from the hyperecho mechanism but the result, when applied to TSE, is very similar: rf power can be considerably reduced without any loss in signal intensity. TRAPS is based on the quite benign signal behavior of spins, once they have entered the so-called static pseudo-steady state (sPSS) [5]. After the sPSS has been reached, it can be shown that flip angles can be varied quite freely without any loss of coherence. Consequently the signal intensity can be driven back to 100 % by gradually increasing the refocusing flip angles to 180° for the signal encoding for the center of k-space. Fig. 4 shows flip angles and signal intensities for a rather simple implementation of TRAPS with linearly increasing flip angles to 180° and a subsequent linear decrease to the end of the echo train. Signal intensities again show the increase at TE eff compared to the fully refocused sequence. For this particular implementation the SAR was reduced to ~ 40 %. Fig. 5 shows a TRAPS-image acquired on a 3T system (MAGNETOM Trio) (ETL 27; 508 x 512 matrix; SLTH 2 mm; Flip 60°; TE/TR = 109/6000 ms; FOV 19.1 x 24 cm) demonstrating the exceedingly good image quality achievable with this technique. For HASTE experiments, which use very long echotrains with short ESP, the reduction of SAR is especially important and relevant even at 1.5 T. Fig.6 demonstrates the improvement in imaging efficiency with a reduction of the required TR by a factor of

almost 4, which allows multislice applications with good volume coverage and sufficiently short acquisition times even to allow breath-hold imaging. Comparing TRAPS with hyperechoTSE [Fig. 1a vs. 4a], it is noted that the hyperecho mechanism allows a quite fast transition from low to high flip angles, whereas in TRAPS flip angle variations should in general stay with +/- 20° in subsequent refocusing periods. The signal variation in TRAPS is thus more gradual, but the SAR-savings are in general a little more modest compared to hyperechoes. This has been taken into account in the implementation of the sequence in the wip-package “Hyperecho TSE”. The decision on the best strategy is made by the program strategy, taking into consideration the relevant imaging parameters. The user can therefore continue to use TSE with considerably reduced SAR without having to worry about the intricacies of signal formation. A more flexible wip-package for expert users, where the relevant parameters are set through the “Special Card” of the “Sequence” menu, can also be made available.

References
[ 1 ] Hennig J, Nauerth A, and Friedburg H: RARE imaging: a fast imaging method for clinical MR, Magnetic Resonance in Medicine 1986; 3:823-833 [ 2 ] Hennig J, Scheffler K, Easy Improvement of Signal-to-Noise in RARE sequences with Low Refocusing Flip Angles Magn Reson Med. 2000; 983-985. [ 3 ] Hennig J, Scheffler K, Hyperechoes, Magnet Reson Med 46(1):6-12 (2001) [ 4 ] Le Roux P, Hinks RS. Stabilization of echo amplitudes in FSE sequences. Magn Reson Med. 1993; 30:183-90. [ 5 ] Alsop DC. The sensitivity of low flip angle RARE imaging. Magn Reson Med. 1997; 37:176-84. [ 6 ] J. Hennig, T. Kluge, K. Scheffler. Multiecho Sequences with Variable Refocusing Flip Angles: Optimization of Signal Behavior Using Smooth Transitions between Pseudo Steady States (TRAPS). Proc. Xth ISMRM Honolulu, p.2365 (2002)

Take-home message
Given the fact that progressing from 1.5 to 3 T is roughly equivalent to a 4-fold increase in rf-power, this leads to the following “take-home message”: Hyperecho-TSE allows one to perform TSE-imaging at high fields under similar conditions offered by the conventional sequence at 1.5 T. The full wealth of TSE-based imaging protocols is therefore available after suitable adaptation of the contrast to the changes in T1 and T2.

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KAPITEL

Siemens Ultra High-Field Program
www.SiemensMedical.com
A91100-M-Z730-1-7600

The Siemens commitment to 3 Tesla can easily be seen in our leading product line in the Ultra High-Field segment. MAGNETOM® Allegra – See the Mind. Dedicated to brain imaging, this most compact 3T scanner is equipped with the strongest gradients in the market. MAGNETOM Trio – See the Body. The Trio is your system for whole body applications in the 3T Ultra High-Field sector. It offers a full 40 cm Field of View and is the shortest 3T scanner allowing clinical whole-body imaging at 3 Tesla. Siemens Medical Solutions that help

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MAGNETOM FLASH 3

Cognitive Neuroscience Center at the Singapore General Hospital
Cécile Mohr, Ph.D. Ultra High-Field Segment Market Manager MR Division, Siemens AG Medical Solutions, Erlangen Germany

Principal Investigator: Dr. Michael Chee M.D

What we do
The Cognitive Neuroscience Laboratory uses functional magnetic resonance imaging (fMRI) to study the organization of the bilingual brain. We seek to uncover the neural correlates to understand why some persons are more adept at learning a second language than others. fMRI harnesses the fact that regional increases in blood flow occur in a task-dependent manner. For instance, thinking about words activates parts of the brain that are involved in language processing, whereas the passive viewing of a flashing checkerboard activates visual areas. This change or modulation in regional blood flow is detectable by magnetic resonance imaging: however, since the signal change is small and the background noise is relatively high, careful design of experiments and thoughtful data analysis are required to draw meaningful inferences about how the brain works. The team carrying out this research comes from varied backgrounds. The principal investigator is a neurologist with special training in clinical neurophysiology and an interest in cognitive neuroscience. Also on board are graduates in computer science and psychology. The lab collaborates with physicists from Duke University and 44

Figure 1 Delivery of the MAGNETOM Allegra to the Cognitive Neuroscience Center at the Singapore General Hospital

Figure 2 Dr. Michael Chee, Neurologist and Principal Investigator of the Cognitive Neuroscience Laboratory, Singapore General Hospital, in front of his MAGNETOM 3T Allegra. Dr. Chee's interest is in studying why individuals differ in their capability for second language acquisition. The increased sensitivity for functional MRI studies offered by 3 Tesla MR scanners, as well as the scanning speed needed for such studies, are excellent reasons why Dr. Chee has decided to acquire a MAGNETOM Allegra – the 3T MR scanner with the fastest gradients in the industry (40 mT/m per axis or 69 mT/m effective and a slew rate of 400 mT/m/ms). “Apart from purely technical considerations, the choice of the Allegra was also due to my confidence in Siemens post sales technical service, a factor investigators ignore at their peril”, says Dr. Chee.

Figure 3 Research team Back row: Steve Graham Ph.D. Experimental Psychology (memory), Chun Siong Soon BSc BA, Physics and Philosophy (language), Chris Westphal BSc Psychology (memory), Vinod Venkatraman MSc Computer Science (methods development) Joshua Goh BA Hons (memory) Front row: Hwee Ling Lee BA (language), Mike Chee M.D (prinicipal investigator)

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the University of Freiburg, a neurologist at Massachusetts General Hospital, Boston and with psychologists from the National University of Singapore and the National Institutes of Education.

Figure 4 Glowing beauty…. No, this is not the latest MAGNETOM Allegra design! This visual effect is caused by the projector located behind the magnet. The projector is used for presentation of visual stimulation to patients and subjects undergoing a functional MRI examination at the Cognitive Neuroscience Laboratory.

Background
A matter of increasing importance in an increasingly globalized world is how to deal best with the challenge of communicating in multiple languages. The need to acquire one language (English) as the language of business, technology and international communication competes with personal, cultural and political needs to preserve some sense of distinctiveness within a particular group of people. Questions previously of interest to scholars have only now become important to policy makers: Does the concept of critical periods of development apply to second language learning? How flexible is the brain in terms of its organization with respect to language? What kind of changes occur in the brain when one learns a second language? Are there any predictors for proficiency or is the attainment of proficiency merely a function of practice? Whereas previous knowledge on functional anatomical relationships has been dependent on the occurrence of brain lesions or epilepsy, functional MRI affords the study of language processing in healthy volunteers without exposure to ionising radiation.

and older studies that suggested separate areas for different languages is that previous studies did not take into account proficiency differences. We found that these may modulate activation on account of the greater cognitive effort required to process words in one’s less proficient language. Arising from this, we also found that word frequency reliably modulates brain activation providing a means of indexing exposure-dependent modulation of brain activation. We propose using this device to track brain activation changes during the course of language acquisition. We are concurrently working on the neural correlates of how phonological skills relate to language acquisition capacity.

Representative Publications:
[ 1 ] Chee MW, Buckner RL, Savoy RL. Right hemisphere language in a neurologically normal dextral: a fMRI study. Neuroreport 1998; 9(15): 3499-3502 [ 2 ] Chee MW, Buckner RL, O’Craven KM , Bergida R, Rosen BR, Savoy RL. Auditory and Visual Word Processing Studied with fMRI. Hum Brain Map 1999; 7(1): 15-28 [ 3 ] Chee MWL, Tan EWL, Thiel T. Mandarin and English single word processing studied with fMRI. J Neuroscience 1999 19:3050-3056. [ 4 ] Chee MWL, Caplan D, Soon CS, Sriram N, Tan EWL, Thiel T. Weekes. B. Processing of visually presented sentences in Mandarin and English studied with fMRI. Neuron 1999, 23:127-137. [ 5 ] Chee MWL, Weekes B, Lee KM, Soon CS, Schrieber A, Hoon JJ, Chee M. Overlap and Dissociation of Semantic Processing of Chinese Characters, English Words and Pictures: Evidence from fMRI. Neuroimage 2000; 12: 392-403. [ 6 ] Chee MWL, Sriram N, Soon CS, Lee KM. Dorsolateral prefrontal cortex and the implicit association of concepts and attributes. Neuroreport 2000; 11: 135-140. [ 7 ] Chee MWL, Hon N, Lee HL, Soon CS. Relative language proficiency modulates BOLD signal change when bilinguals perform semantic judgements. Neuroimage 2001; 13:1155-63. [ 8 ] Chee MWL, Hon N, Caplan D, Lee HL, Goh J. Frequency of concrete words modulates prefrontal activation during semantic judgments. Neuroimage 2002:16:259-268 45

Where do we see ourselves in two to five years?
Our work will continue to relate to human cognition and involve language and memory in particular, but we expect to shift into more clinically related areas in work relating to human memory. In the language domain, we will work with other laboratories to determine the functional-anatomical correlates of individuals with differing capacity to acquire a second language. In the memory domain, we hope to study the functional-anatomical correlates of human memory under conditions of sleep deprivation and aging and to evaluate the effects of intervention, whether pharmacological or behavioral, on these.

What we have discovered
We have shown that in fluent bilinguals, similar brain regions are activated during single word and sentence level processing in two dramatically different languages: English and Mandarin. We have also established that processing of Chinese characters for meaning does not differ significantly from the processing of English words for meaning and that these differ from the processing of pictures for meaning. One explanation for differences between recent studies on the bilingual brain

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Center of Excellence in Cardiovascular Imaging, Australia
Tony Enright, Ph.D. Asia Pacific Collaboration, Australia

Summary
The MIA (Medical Imaging Australasia) Group has identified noninvasive cardiovascular imaging with magnetic resonance imaging (MRI) and multi-detector computerised tomography (MDCT) as the future of cardiovascular imaging. Siemens shares this vision with their latest cardiovascular technologies in MRI and multi-slice detector CT, Siemens MAGNETOM Sonata MRI scanner and SOMATOM Sensation 16 CT. “There is presently no other center in Australia with this combination of technology working side-by-side for the diagnosis of cardiac diseases. It is a unique opportunity to evaluate within Australia the clinical roles of these new technologies in the provision of cardiovascular care services and patient wellness.” Key to the success of this vision is the collaboration between the Radiology and Cardiology fraternities in order to unite the expertise and know-how of Radiology with the experience of Cardiologists in the fields of myocardial and coronary imaging. This is Adelaide Cardiac Imaging (ACI), a collaborative venture between a Cardiology and Radiology group for the purposes of providing clinical excellence in the cutting-edge fields of cardiovascular imaging with MRI and MDCT. This collaboration encompasses the sharing of financial, administrative and technical aspects of the program.

Figure 1 Adelaide Cardiac Imaging Team. Left to right : Radiologist Dr. Shaun Fowler, Cardiologist Dr. Daniel Cehic, Cardiologist Dr. Stephen Worthley, Radiologist Dr. Charles Lott, Cardiologist Dr. Michael Brown With the formation of ACI, there is a substantive investment made into the clinical research of cutting-edge diagnostic protocols for cardiovascular care, which have only recently become available with state-of-theart techniques, such as coronary MR angiography and plaque imaging. Employing new Siemens MRI and CT scanners, the center will combine clinical excellence with research. Siemens supports this initiative through a close collaboration with Siemens Global Development groups and its Cardiovascular Research and Development facility, located at Northwestern University in Chicago. “Together with the clinical skill sets involved in ACI, this center has the credentials for growth to a world class center of excellence in cardiovascular imaging.”

Why the focus on cardiovascular diseases?
In the Western World cardiovascular disease is the single leading cause of mortality. Rapidly developing magnetic resonance imaging (MRI) and computed tomography (CT) scanners are allowing clinicians to develop new methods for treating complex cardiovascular problems and researching cardiovascular disease.

Clinical Skill Sets for Excellence in Cardiac Imaging
From a clinical perspective it is the skill sets, brought together in a close collaboration of cardiology and diagnostic imaging, that point the way to success in this challenging field. Dr. Stephen Worthley, an interventional cardiologist who has completed a Ph.D. thesis in MRI and coronary atherosclerosis at the Mount Sinai Medical Center in New York, continues his successful career in clinical

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Figure 2 Dedicated task card with syngo including automatic cine display, postage stamp reference images, ecg graphics and triggering setup.

Figure 3 Argus cardiac post processing software with functionalities like ventricular function assessment, quantitative flow assessment, multipanel cine review, avi movie maker.

day running of the cardiovascular imaging program with MRI and MDCT – a collaboration that is Adelaide Cardiac Imaging. and academic cardiology with the ACI program. In the last 5 years alone, Dr. Worthley has published more than 80 manuscripts and abstracts in the fields of cardiovascular imaging and intervention, and authored book chapters on Cardiovascular MRI, including for the prestigious cardiac text, “Hurst’s The Heart”. He holds a number of grants for research into the utility of MRI and intravascular ultrasound for imaging atherosclerosis, including projects that are ongoing in both Melbourne and Adelaide in Australia. Dr. Worthley joins the Adelaide Cardiology group (Fig. 1) together with a dedicated group of Radiologists (Dr. Shaun Fowler and Dr. Charles Lott) and Cardiologists (Dr. Michael Brown and Dr. Daniel Cehic) who together are involved in the day-toIn addition to a world-wide team of experts, the ACI program can only be supported by imaging technology and especially by MRI scanners able to be operated by cardiologists, placing cardiology at the forefront of the examination of one of the most challenging organs – the heart. In this respect, the MAGNETOM Sonata’s Maestro user interface (Fig. 2) is designed with unique features targeting the needs of cardiology. 47

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“With this scanner we expect traditional interactions between radiology and cardiology to change, placing radiologists together with cardiologists like Dr. Worthley, operating the console guiding and planning the patient’s examination. This direct involvement of cardiologists is a crucial point to ensure success in validating new cardiac imaging techniques.”

New Clinical Services Offered to Patients in Australia
ACI is the first center in Australia to offer state-of-the-art non-invasive cardiac imaging to the people of South Australia. Along with a comprehensive suite of cardiovascular services, ACI offers new care services, such as Chest Pain Investigation: referrals for non-invasive coronary angiography can undergo noninvasive tests on MRI or 16-slice multi-detector CT. An extensive program for Cardiovascular Risk Assessment also offers: a. Conventional Risk Factor Review b. Cardiovascular MRI: non-invasive evaluation of heart function (Fig. 3) and direct imaging of atherosclerosis c. Coronary Calcium Scoring: noninvasive calculation of calcification in the coronary arteries, a predictor of risk for future heart attacks d. Physician Review

Figure 4 Cardiac imaging with GRAPPA technique. Imaging parameters: GRAPPA x 2, TR 35 msec, 7 second breath-hold 298 x 256 pixels, 262 mm x 300 mm FOV, 0.88 mm x 1.17 mm x 7 mm voxels

other center in Australia with the SMASH-based technology GRAPPA, introduced on the MAGNETOM Sonata to address the limitations in SENSE technologies for cardiovascular imaging applications. The GRAPPA technique helps reduce breath-hold duration, therefore making the examination even more comfortable for patients. In addition, the GRAPPA technique ensures the best image quality thanks to a unique technology called Auto-Calibration.” (Fig. 4)

Cardiovascular examinations with the MAGNETOM Sonata avoids patient exposure to radiation by using magnetic resonance imaging. SOMATOM Sensation-16 minimises radiation exposure by employing optimised scan protocols and dose modulation technology. ACI have the expertise to decide which is the best diagnostic technique for their patients.

The new 16-slice CT technology introduced with SOMATOM Sensation-16 now brings into view new diagnostic information in imaging coronary artery disease and cardiac function. The SOMATOM Sensation 16 is the ultimate multi-slice CT solution offering virtually unlimited isotropic volume acquisition with 16 simultaneously acquired slices, without compromising clinical applications. ACI will be the first recipient of the Sensation-16 in the whole of Australia. Both scanners operate on a multimodality user interface – Siemens syngo – allowing clinical personnel to cross-train on all imaging modalities. syngo creates new ways of looking at image data and integrates MRI and CT data together for a comprehensive diagnosis. “This is the first center of its kind in Australia and one of only a few hospitals world-wide to boast such a combination of MAGNETOM Sonata and SOMATOM Sensation-16, combining high performance in MR and CT for cardiac diagnosis and care.”

More on the Technology
The technologies underpinning this venture include an MRI scanner designed to support the demanding requirements of advanced MR imaging applications, such as cardiovascular examinations. MAGNETOM Sonata features the highest level of speed available in the industry. ACI is the first center in Australia to evaluate in clinical practice side-by-side both parallel imaging technologies SENSE and SMASH – new imaging techniques which speed up the examination times. “There is currently no

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A Collaboration to Foster Further Innovations
Siemens has invested heavily in the support of research and advanced clinical applications worldwide, especially in cutting-edge projects such as the one in ACI. This is a deliberate strategy by Siemens to maintain its place at the top of the technology pyramid and, as such, is becoming increasingly the partner of choice for customers such as ACI, operating advanced applications. “MRI offers rapidly advancing and improving technologies which we can pass on to our key collaboration partners, since this growth is sustained only by close collaboration with groups who have the necessary skill sets and who are willing to work at the forefront of these applications and their clinical evaluation. ACI have made a major investment into cardiovascular research, and validation of emerging technologies. ACI is therefore a strong partner for this collaboration, with a commitment to clinical excellence and education”. Siemens supports this venture with close cooperation with Siemens Global Development groups in Europe and the US, as well as Siemens Cardiac Research and Development facility located at Northwestern University in Chicago. This collaboration is facilitated by several Siemens physicists and engineers. To ensure that the entry level of this technology sets the standard for Australia, there is provision for the training of clinical staff at established centers of excellence overseas. This is backed up by the local and direct support of an Asian-Australian Applications Scientist, as well as priority Applications Support from Siemens trained Applications Team.

Figure 5 Cardiac Ambassadors at New York meeting Adelaide Cardiac Imaging will participate in Siemens Cardiac Ambassadors Club Meetings, the latest held in New York in June. There, ACI group was able to share its experience with international clinical experts, as well as with Siemens Medical scientists. Siemens Cardiac Ambassador Club is the ultimate users club providing interactions with a high-level peer network of key global clinical researchers in cardiac, and the chance to participate in steering Siemens future technology growth in this area. (Fig. 5)

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Cardiac Ambassadors Meeting, New York, June 27-29, 2002

Figure 1 Cardiac Ambassadors Daisy Chien Ph.D. Siemens AG The Cardiac Ambassadors Meeting held in New York this summer proved to be a great success. More than 100 people attended, including 85 users from 15 countries (Fig. 1). Close to 20 colleagues from Siemens Erlangen, Siemens Iselin, and Siemens Corporate Research Princeton were present to support the meeting. Local Siemens offices sent out the invitations to a representative from each cardiovascular MR reference site, which received an enthusiastic response from many sites worldwide. In addition to the discussion forum, there was a hands-on demonstration session in which new software (syngo 2002B) and postprocessing tools were shown. There were also demonstrations of the new Argus and Vessel View software. Dr. Brett Cowan, from Auckland, New Zealand, showed his 3D modeling software, which generated much interest among the audience. A number of centers prepared posters highlighting their centers and their work. Furthermore, many participants prepared interesting cases to share with each other. During one of the demonstration sessions, Dr. Charles Cheng (HealthTech International, Taiwan), Dr. Vicente Martinez (ERESA Imaging Center, Spain) and Dr. Corinna Cozeb Poetica (Klinikum Krefeld, Germany) highlighted and discussed interesting cases. Dr. Barkhausen, Dr. Heiko Mahrholdt, and Dr. Anja Wagner were also available to give an analysis of their clinical results. After much intensive work together, the participants went out on the town for an enjoyable evening in which a fine dinner was followed by tickets to the glamorous Broadway show 'Aida'.

Second Day
The second day consisted of summaries of the focus sessions given by Siemens users. This provided all participants with an excellent overview, as they had not been able to attend selected focus sessions that ran in parallel with other sessions. The Siemens presentations highlighted new features in the product, as well as new techniques and innovations, to inform participants of new and important developments. It was a very fruitful exchange for everyone present. The response from the participants was very positive and the questionnaire results more than confirmed the importance and effectiveness of the meeting. The scores are set out below. An important aspect of this meeting was the opportunity for an open forum for interaction among users worldwide. Many participants appreciated the chance to meet and get to know colleagues who are active in cardiovascular MR.

First Day
After a welcome dinner and gettogether, the first working day consisted of parallel focus sessions on a number of topics. The special focus sessions included TrueFISP imaging, parallel imaging, coronary MRA, angiography, viability imaging* , plaque imaging*, perfusion*, stress imaging*, function, flow, pediatric CMR, spectroscopy, education, business models, reporting and viewing. For each of the sessions, a Siemens user was asked to give a summary of the discussion on behalf of the group on the following day. 50

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Survey results from the CMR Ambassadors
Rating was from 1 to 5 (1 = ineffective; 5 = highly effective)

Question Overall effectiveness of the meeting How well interests were addressed Openness of exchange between customers Helpfulness of Siemens’ contribution

Mean Score 4.7 4.6 4.5 4.4 4.9

Importance of the Meeting

After the meeting, a site visit was made to the Mount Sinai Medical Center (Fig. 2). Dr. Zahi Fayad, Dr. Michael Poon, Mr. Frank Macaluso, and Mr. Paul Wisdom graciously hosted the “open house”. The Mount Sinai team was there to share with us their experience of performing CMR, using their newly installed Sonata system. The users were enthusiastic about discussing the interesting cases that they have been working on.

Figure 2 Site visit of CMR Ambassadors to Mount Sinai Medical Center.

* “This information concerns a use of contrast media that has not been approved by the Food and Drug Administration”. (21 CFR 99.103 (a) (1) (i).

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Duke University Cardiac MR Center
Daisy Chien Ph.D. Siemens AG

Figure 1 Duke University

The department of Cardiology at Duke University is ranked as one of the top five in the nation and the best in the south. Dr. Raymond Kim and Dr. Robert Judd were recruited recently from Northwestern University to Duke University to head the Duke Cardiovascular MR Center. Dr. Kim and Dr. Judd have built up a team of enthusiastic clinicians and researchers that work in close collaborations with the cardiologists as well as the radiologists.

The Center has purchased two Siemens MR scanners dedicated for cardiovascular imaging. The first system (Sonata Maestro class) has been installed and scanning started in mid-July 2002. This system is used 50 % for clinical examinations and 50 % for research. The second system (also a Sonata Maestro class) will be installed at the end of the year next to the catheterization labs (on the 7th floor of the main hospital) and will be used 100 % for clinical work.

Figure 2 Sonata Maestro class in Duke University Cardiac MR Center.

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Figure 3 Dr. Raymond Kim, Clinical director of Duke CMR Center

Dr. Raymond Kim, Clinical director of the Duke CMR Center, says, “We see a blossoming of CMR in the clinical realm. The past and recent research results have transformed this field into true clinical reality.” “We have been working with Siemens for the past 5 years both on the research side as well as the clinical side. The MAGNETOM system is excellent, but it is not just the hardware and software, but is really the people. Working with Siemens has been a good experience for our collaboration.”

Figure 4 Heiko Mahrholdt, M.D. Duke Cardiovascular MR Center, NC, USA and Robert Bosch Medical Center, Stuttgart, Germany: “One of the most important recent developments in CMR is infarct assessment by late enhancement*. This technique will change the clinical approach to the diagnosis of myocardial infarction*.”

Figure 5 Subendocardial infarcts seen with MR late enhancement technique.

Trans-Atlantic Collaborations
The Duke Cardiovascular MR Center has visiting fellows from other countries and the Center also has a close collaboration with Prof. Udo Sechtem at the Robert Bosch Medical Center in Stuttgart, Germany. Dr. Heiko Mahrholdt (Fig. 4) and Dr. Anja Wagner (Fig. 6) are both employees of the Robert Bosch Medical Center and are heavily involved in research studies. Previously they were at the Northwestern University and now at Duke Cardiovascular MR Center.

A research study which has major clinical significance is the study titled: “Contrast-enhanced MRI detects subendocardial myocardial infarcts that are missed by routine SPECT perfusion imaging.” by A. Wagner, H. Mahrholdt, et al. from Northwestern University, Duke Cardiovascular MR Center, and Robert Bosch Medical Center. This study evaluated the ability of MR and SPECT to detect subendocardial infarct. 91 patients were examined by both modalities. In addition, an animal model was used to provide histological comparison. The results showed that for transmural infarcts, there was good correlation between MR and SPECT. However, for subendocardial infarcts, MR was able to detect the infarcts which were missed by SPECT. This result has significant implication on the ability of MR to guide therapy, e.g., in the use of beta blockers in patients with subendocardial infarcts.

Figure 6 Anja Wagner M.D. Duke Cardiovascular MR Center, NC, USA and Robert Bosch Medical Center, Stuttgart, Germany “Contrast-enhanced CMR imaging detects subendocardial infarcts which are missed by routine perfusion SPECT scans. This finding should have significant consequences for the routine cardiology practice.”

Ongoing studies include the investigation of MR studies after injecting Gadolinium tagged embryonic stem cells into the myocardium. The hypothesis is that the embryonic stem cells tagged with Gadolinium can be followed by MR imaging to evaluate its subsequent function as an integral part of the myocardium.

* “This information concerns a use of contrast media that has not been approved by the Food and Drug Administration”. (21 CFR 99.103 (a) (1) (i).

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MR Angiography with Integrated Parallel Acquisition Techniques (iPAT)
David Thomasson, Ph.D. Siemens Medical Solutions USA, Inc.

Methods
There are two parallel acquisition strategies in the Siemens implementation of iPAT, making it the most comprehensive parallel imaging solution on the market. While both require integrated panoramic coils for obtaining the multiple data sets used to reduce scan time, each technique has its own particular strengths relative to specific clinical applications. These methods are best understood in terms of how they combine the individual coil data sets to generate the final “reconstructed” image. It is important to understand that all MR images are reconstructed from raw data that is Fourier-transformed into image data. In order to implement any iPAT method of speeding up this process, data from multiple coils must be combined to generate the final image. Modified Sensitivity encoding (mSENSE) combines the multiple data sets obtained from individual coils after the raw data is Fouriertransformed into individual image sets. The second strategy, Generalized Partially Parallel Acquisition (GRAPPA), combines individual coil raw data before a Fourier-transform is applied to produce the final reconstructed image. Due to these subtle reconstruction differences, it can be shown that some imaging tasks are best suited to mSENSE while others are more appropriately performed with GRAPPA.

Introduction
MR angiography (MRA), and more recently contrast-enhanced MR angiography (CE-MRA), are wellestablished methods of evaluating vascular structures and can be used literally from head to toe. Standard Time-of-Flight (ToF) techniques are used in neurological studies; CE-MRA and ToF are used to image the carotids, the aorta, the pulmonary and the renal arteries, and the vasculature in the extremities (peripheral angiography). Standard ToF neuro-angiography is well known for evaluating pathology in the brain, where the contrast to noise is quite good since flowing spins are unsaturated (bright) against a saturated background brain tissue signal. This high intrinsic contrast to noise makes it particularly well suited to iPAT, wherein imaging times can be significantly reduced. CE-MRA, which has revolutionized almost all standard MR angiography techniques, is also particularly well suited for iPAT due to its high intrinsic contrast-to-noise ratio. However, there are several ways in which iPAT can be implemented, and these new techniques need to be judiciously matched to the appropriate clinical applications in order to obtain optimal results.

mentations of GRAPPA (conceptually similar to SMASH) were limited to linear arrays of coils, and typical neuro anatomy was not suited to this coil design. However, mSENSE reconstruction techniques could easily use arbitrary coil configurations. Here we show how mSENSE can provide high quality neuro angiograms (Fig. 1) in a significantly reduced scan time using an 8-channel head array coil.

Figure 1 (TOP) Conventional MRA (TA = 5:26),(Bottom) MRA with mSENSE (PAT factor 2) (TA = 3:09) These images were obtained on a MAGNETOM Siemens Symphony Quantum using an MRI Devices 8-channel head array coil that is compatible with the Siemens implementation of iPAT.

Results
ToF Angiography with mSENSE With mSENSE, fold-over can be an issue. However, for most neuro applications, this has never been a significant problem as the anatomy easily conforms to standard matrix and FoV applications. The first imple-

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Figure 2 512 matrix with 80 partitions (voxel dimensions: 1.3 x 0.8 x 1.8 mm). (TA = 19 s) CE Abdominal MR Angiography with GRAPPA In other applications, GRAPPA is the technique of choice, because its reconstruction algorithm is more robust for anatomy where wrap or fold-over artifacts are of concern. With a 6-channel body array coil, we can phase-encode left to right in a linear fashion, therefore we can use GRAPPA without worrying about significant wrap-around artifacts. This MIP image (Fig. 2) was obtained at the University of Essen (Germany) on a MAGNETOM Sonata equipped with two 6-channel array coils and using GRAPPA with an iPAT factor of 2 (acquisition time: only 19 s). The 3D data set consists of 80 partitions; using 24 ml of Magnevist, the signal to noise is quite good, with no wrapping artifacts.

Figure 3 These images were obtained at Mount Sinai School of Medicine, New York City, USA, on a MAGNETOM Sonata, using a runoff technique comprised of GRAPPA x2, a single bolus injection, and four stations. Each station had an acquisition time of 9.6 seconds (512 matrix with 2 mm slice thickness).

Conclusion
Integrated parallel acquisition techniques (iPAT) can significantly reduce imaging time when there is sufficient intrinsic contrast-to-noise, or they can improve spatial resolution for techniques that are bounded by time constraints, e.g. breath-hold imaging. There are two basic techniques for iPAT: mSENSE, which is best suited for arbitrary coil geometries; and GRAPPA, which is best suited for applications where coil configurations are not limited by over-folding. Together, these techniques offer a comprehensive parallel imaging solution for maximum flexibility. [ 1 ] Klaas P. Pruessmann, Markus Weigner, Markus B. Scheidegger, and Peter Boesiger. SENSE: Sensitivity Encoding for Fast MRI, Magnetic Resonance in Medicine 42: 952-962, 1999 [ 2 ] D.K. Sodickson, W.J. Manning. Simultaneous Acquisition of Spatial Harmonics (SMASH): Fast Imaging with Radiofrequency Coil Arrays, Magnetic Resonance in Medicine 38: 591-603, 1997 [ 3 ] Mark Griswold, Peter Jakob, Robin Heidemann, Mathias Nittka, Jiamin Wang, Berthold Kiefer, Axel Haase. Push-button PPA Reconstructions: GeneRalized Autocalibrating Partially Parallel Acquisitions (GRAPPA). Proc. Intl. Soc. Mag. Reson. Med. 9, 2001

CE Peripheral MR Angiography with GRAPPA In peripheral angiography, GRAPPA is also the technique of choice, because its reconstruction algorithm is more appropriate for linear arrays of coils. With an integrated panoramic array (IPA) compatible peripheral angio coil, we can apply GRAPPA to maximum advantage.

* iPAT is available on Maestro Class 1.5T MAGNETOM systems running syngo 2002B.

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Contrast Enhanced MR Demonstration of Thoracic Central Veins
Andrew Holden M.D. Department of Radiology Auckland Hospital, New Zealand A major clinical application for this technique is the renal failure patient on hemodialysis. Central venous stenoses frequently complicate arm dialysis grafts, with possible etiologies including barotrauma or direct catheter irritation of the central veins. If a forearm dialysis graft is planned (or an existing graft is failing), assessment of central vein patency is important. Patients with malignancy and central venous compression may also benefit from this technique. While a similar technique of indirect venography is possible with CT, this involves significant patient radiation. Osseous structures would also reduce image quality on CT, despite subtraction. The patient imaged (Fig. 1) is a renal failure candidate for a possible forearm dialysis graft. The patient has had previous central venous catheters, possibly with central venous occlusions. The first image is acquired in the arterial phase after intravenous contrast injection via a right arm vein (Fig. 1). The second acquisition has contrast in thoracic arteries and veins (Fig. 2). By subtracting the “mixed arterialvenous” data set from the “arterial only” data set, images of the central veins alone can be obtained. In this case (Fig. 3), there is occlusion of the right subclavian vein (short arrows) as well as the left internal jugular and brachiocephalic veins (long arrows). This technique has provided an excellent overview of central venous anatomy which would otherwise be extremely difficult to obtain. Figure 3 Subtraction image showing the central veins

The desire to produce anatomical detail of central thoracic veins provides a challenge for invasive and non-invasive imaging. Conventional venography can show details of subclavian and brachiocephalic veins, but this requires bilateral arm contrast injections, details of jugular veins anatomy will not be demonstrated by this technique. Technique of indirect MR Venography Gadolinium-DTPA (20 ml followed by 20 ml saline) is injected via an arm vein and 3 D T1-weighted gradient echo sequences of the upper chest/ thoracic outlet is performed on the MAGNETOM Symphony Quantum 1.5T system. Images are acquired in arterial and venous phases and then ‘venous only’ images constructed by subtraction of the two data sets.

Figure 1 Arterial phase

Figure 2 Late phase showing both thoracic arteries and veins

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MAGNETOM Sonata Always a step ahead!
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[Maestro Class]

A91100-M-Z764-1-7600

intelligence – MAGNETOM® Sonata with in-line technology processing instead of postprocessing increased speed – one of the strongest gradient systems and iPAT. innovative applications – cardiac, for instance. One-stop cardiac imaging provides speedy answers, including evaluation of morphology, angiography, ventricular and valve functions. With these and more you’re always a step ahead.

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Assessment of Myocardial Viability by “Late Enhancement*”
Friedrich Fuchs M.D. Siemens AG Medical Solutions, Erlangen Germany Electromechanical Mapping: EMM can assess myocardial viability on the basis of myocardial voltage in the left ventricle. The distinction between dysfunctional, but viable myocardium and nonviable myocardium, however, is often difficult to identify by using the above mentioned diagnostic procedures, especially in patients with acute myocardial infarction and severely impaired left ventricular function.

Cardiac MR
Over the last decade cardiac MR (CMR) has become an acknowledged standard method for evaluation of cardiac anatomy, morphology and function. CMR is also able to assess myocardial viability with a technique called ‘Late Enhancement’. It has been demonstrated that extracellular MRI contrast agents, like Gd-DTPA, accumulate only in irreversibly-damaged myocardium after a time period of at least 10 minutes. After this time period, Gd-DTPA concentrations do not differ as between reversiblyinjured myocardial segments and remote myocardium. Accordingly, ‘Late Enhancement’ can identify the presence and extent of irreversiblydamaged myocardium in patients with CHD (Coronary Heart Disease). In comparison with other techniques spatial resolution is higher with MR in the submillimeter range. CMR is the first diagnostic method able to differentiate subendocardial myocardial infarct from transmural infarct in vivo. Even the real transmural extent of irreversibly-damaged myocardium can be determined accurately. Unlike the diagnostic methods for assessment of myocardial viability referred to above, the L.E. technique does not need exercise or pharmacological stress testing. In contrast to nuclear medicine and PET, the results are displayed without any time delay. The acquisition time for ‘Late Enhancement’ images is also very fast and the evaluation very easy, so that decisions concerning patient management can be made immediately after the MR examination. As far as the accuracy of defining infarcted regions is concerned, ’Late Enhancement’ highly correlates with the results achieved by PET, the

The assessment of myocardial viability is essential for optimal management of patients with myocardial infarction, because only viable myocardium will benefit from the revascularization procedures – PCI (Percutaneous Coronary Intervention) or CABG (Coronary Artery Bypass Graft). For the evaluation of myocardial viability, different diagnostic procedures are currently available for clinical routine: ECG: Significant Q-waves and/or loss of R-waves indicate transmural myocardial infarction. Echocardiography: Under rest condition, myocardial wall thinning (< 5 mm) and akinesis of wall segments indicate that these segments are not viable. Further study of primarily akinetic wall segments with low-dose-dobutamine stress can identify viable wall segments by inducing contraction (contractile reserve). Nuclear medicine: Thallium 201 redistribution scintigraphy is the method most often used in nuclear medicine to identify viable myocardium. PET: Since viable myocardium is perfused and has metabolism, PET can identify viable myocardium by use of FDG (Fluorodeoxyglucose), indicating viable myocardium and/or NH3, indicating perfused myocardium. 58

There are further limitations:
s The accuracy of viability assessment by ECG is not very high, especially the diagnostic value of nonpresent Q-waves. s Image quality in echocardiography is not satisfactory in ~ 20% of people, due to poor acoustic window. s Nuclear medicine and PET offer only limited spatial resolution (~ 10 mm), so that smaller myocardial infarctions might not be detected. s PET and EMM are only available in some centers. s Nuclear medicine and PET use ionizing radiation, are timeconsuming and expensive.

The conclusion to be drawn from the above is that cardiology would benefit enormously from a diagnostic method for assessment of myocardial viability which is accurate, fast, reliable and cost-effective.

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current gold standard for assessment of myocardial viability. L.E. seems to be superior even to PET in the detection of small myocardial infarctions and scars. L.E. can detect even discrete microinfarctions as demonstrated in patients with coronary one vessel disease who were suspected of having micro-infarcts after PCI. In patients with post-procedural elevation of CK-MB, L.E. was present in the target vessel perfusion territory, even in absence of ECG changes or new wall motion abnormalities.

Segments with a transmural extent of infarction between 25% and 75% demonstrated some improvement in contractility. The working group at NWU was also able to demonstrate a strong correlation between infarction size (defined by L.E.) and peak CK-MB. Neither parameter, however, was of predictive value for regional wall motion improvement following successful revascularization. It follows from the above that L.E. is a robust diagnostic method for assessment of myocardial viability in CHD. With all the advantages of accuracy, time, cost effectiveness and patient friendliness which L.E. has over the diagnostic methods in current use, L.E. opens a new era in the diagnosis of myocardial viability.

Clinical Impact
The clinical impact of ‘Late Enhancement’ has been evaluated in several studies, particularly by the CMR group at Northwestern University Chicago (Dr. Robert Judd, Dr. Raymond Kim), who work closely together with Siemens MR R&D. This collaborative force was able to demonstrate that the transmural extent of infarction, as defined by ‘Late Enhancement’ , predicts in patients with acute myocardial infarction the improvement of contractile function following successful revascularization. The improvement in contractile function was inversely correlated to the transmural extent of ‘Late Enhancement’ before revascularization. In this study, the best positive predictor for wall motion improvement following successful revascularization was the extent of dysfunctional myocardium that showed either no ‘Late Enhancement’ or a transmural extension of less than 25% of the corresponding wall thickness. Wall segments with more than 75% transmural extension of infarction (as defined by L.E.) did not show any improvement of contractility.

Siemens Solution
Siemens is the technology leader in ‘Late Enhancement’ imaging, having developed this technique in close relationship with clinical partners like Northwestern University Chicago. In addition to well established inversion recovery TurboFLASH sequence, Siemens offers ‘Late Enhancement’ MR imaging with single shot TrueFISP and also in a 3D technique. To get optimal image quality, setting of the inversion time (TI) is essential. To find the appropriate TI, which is individual in every patient, Siemens offers a real-time sequence, which automatically changes the TI. This means you get an individual and optimal TI in a very time-efficient manner. All of these techniques are already available as product with syngo MR 2002 B.
* “This information concerns a use of contrast media that has not been approved by the Food and Drug Administration”. (21 CFR 99.103 (a) (1) (i).

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A New Dimension in Cardiac Viability Diagnosis
Dr. Raymond Kim, M.D. Duke University, NC, USA Laboratory findings : Discrete elevation of cardiac enzymes was observed. ECG showed new loss of R-waves in leads v1-v4. (Fig. 1)

Case Report: MR Late Enhancement*
History : 48 year old female patient. She has a known coronary heart disease and a stent was implanted 3 months earlier. The patient also has insulindependent diabetes mellitus type IIB. She reports progressive thoracic pain for the last 4 weeks, that happens after initial freedom of complaints after stenting of the proximal LAD. In the differential diagnosis “Acute Coronary Syndrome”, “Myocardial infarction with post-infarction angina” and “Instable Angina Pectoris” were suspected. Restenosis or occlusion of the stent in the LAD was regarded as the most probable cause of the existing symptoms. Figure 1 ECG findings

Echocardiography showed akinesis of the anterior wall and apex and wall thinning in these areas. (Fig. 2)

Figure 2 Echocardiography images

* “This information concerns a use of contrast media that has not been approved by the Food and Drug Administration”. (21 CFR 99.103 (a) (1) (i).

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Conventional coronary angiography showed occluded stent in LAD and stenosis of marginal branch of circumflex coronary artery. Nuclear medicine showed mostly non-viable myocardium of the anterior wall. (Fig. 3)

Figure 6 Control MR three months after operation.

Figure 3 Nuclear medicine findings Due to these findings a conservative approach should have been followed as due to non-viable tissue. MR was required as an extra step in evaluation of this patient. Segmented TrueFISP cine images (Fig. 4) showed akinesis of anterior and apical wall segments with thinning and also reduced LV function. The MR findings changed the decision of conservative management of the patient and she received a coronary by-pass graft. Three months after the coronary by-pass, wall motion and anterior wall thickening returned to normal (Fig. 6).

Conclusion MR late enhancement technique for diagnosis of myocardial viability is a new and useful tool for improving quality of management of patients with coronary heart disease.

Figure 4 Segmented TrueFISP cine images of the heart

In contrast to nuclear medicine studies, MR showed that the whole anterior wall is viable. Contrast enhanced study of the heart showed no late enhancement of the myocardium (Fig. 5).

Figure 5 No late enhancement suggesting that the whole anterior wall is still viable.

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Clinical MRI of the Breast for Lesion Detection
Todd Frederick RT (R) (MR) and Cynthia Sherry, M.D. Southwest Diagnostic Imaging Center Dallas, TX, USA sub-optimal and will hopefully improve as a result of ongoing research efforts. This article does not attempt to address statistics on the sensitivity, specificity, or accuracy of the MR breast exam, but focuses on the technical issues of performing an optimal MRI of the breast. 3. Spatial resolution The spatial resolution of a breast MR exam must be optimized to allow visualization of small lesions of the breast. Image resolution must also be adequate to accurately depict lesion morphology and characterize lesion margins. As in x-ray mammography, this information is helpful in differentiating benign from malignant masses. [1] Competitive with x-ray mammography, our breast protocols are designed to achieve spatial resolution of 1mm or less in each plane for non-dynamic imaging. 4. Three-dimensional image acquisition techniques are preferred over 2D techniques. 3D imaging allows acquisition of thin, high resolution, contiguous slices plus the ability to reformat images into orthogonal and oblique planes. All breast lesion sequences at our center are acquired 3D and viewed by the Radiologists on an independent workstation. This multi-plane reformatting ability helps to correlate the MR images with mammogram/sonogram findings and to more accurately describe the position of masses within the breast for the purposes of planning interventions. 5. Fat suppression In the normal breast, parenchymal tissue is mixed with varying amounts of adipose tissue. The high signal intensity emanating from fat is difficult to separate from the high signal of enhancing lesions on T1-weighted images. Imaging techniques that suppress signal from fat improve lesion conspicuity and therefore allow more confident lesion visualization and detection. There are two main methods for achieving fat suppression: 1) selective water excitation, and 2) spectrally selective fat saturation. For the gradient echo pulse sequences we use non-dynamic imaging (3D FISP and FLASH), the fastest method of fat suppression is

Introduction
The role of MRI in detecting and characterizing breast lesions is evolving. Roles for both screening and diagnostic breast MRI are being investigated. Screening will probably prove most useful in the segment of patients considered at relatively increased risk of breast cancer. Screening MRI is also frequently beneficial to patients with radiographically dense breast parenchyma or augmentation implants, for whom mammography may be technically limited or inconclusive. Today, most clinical MRI of the breast is diagnostic and is being performed as an adjunct to conventional mammography and ultrasound. Diagnostic breast MRI is indicated in four main categories of patients: 1) Patients with a known breast lesion may be referred to MRI for detection of additional, concurrent lesions not evident mammographically. 2) In the setting of invasive lobular carcinoma, evaluation of the contralateral breast may detect additional mammographically occult lesions. 3) MRI may prove to be the best tool to evaluate post-lumpectomy patients for recurrent or residual disease. 4) The utility of MRI for monitoring response to chemotherapy or ablation therapy* is also promising. Although MRI has been shown to be very sensitive for the detection of breast lesions, the specificity remains 62

Technical Issues in Breast MRI
Seven important technical considerations are addressed: 1. Contrast agent* Breast MRI exams for lesion detection are routinely performed before and after intravenous administration of gadoliniumbased contrast media. A relatively rapid bolus (2 cc/sec) of contrast is necessary to capture the enhancement characteristics of breast lesions. Optimally, data acquisition is complete within five minutes of completing the infusion. 2. Temporal resolution Dynamic acquisition of data following contrast administration can be used to characterize breast lesions and potentially improve specificity. Typically, five separate data sets are acquired throughout the first five minutes following contrast infusion. In order to achieve the temporal resolution necessary for dynamic imaging, spatial resolution – and therefore image quality – must be reduced (see discussion on specific pulse sequence parameters below.) The dynamic images can be evaluated with the syngo MR Mean Curve function on the scan console to plot lesion signal intensity against time. These dynamic enhancement curves can be used to help characterize lesions as benign or malignant. Specifically, fibroadenomas and other benign lesions can often be differentiated from malignancies [1].

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selective water excitation. Although the RF excitation pulse for water excitation requires additional time within the pulse sequence when compared to a conventional RF excitation pulse, it is overall faster (shorter TR and TE) than a spectrally selective fat saturation RF pulse. [2] Both of the fat suppression techniques are very sensitive to field inhomogeneity and center frequency settings. 6. Silicone suppression For those patients with silicone breast implants or intra-parenchymal silicone injections, image quality can be improved by suppressing the high signal arising from silicone. Good silicone suppression can be achieved by manually setting the center frequency (CF) of the sequence 70 to 80 Hz downfield from the CF of water (at 1,5T). By applying a fat-saturation pulse in the subsequent sequence the silicone (300 Hz from water at 1.5 T) will be saturated rather than fat (220 Hz from water at 1.5 T). 7. Dedicated coil The demands for high spatial resolution and temporal resolution can be met only at the expense of the signal-to-noise ratio (SNR). A dedicated breast coil is a necessity to maximize SNR. The Siemens breast coil in use at our facility is a circular polarized array receive coil. There are 2 phased array elements in the coil, and the right or left elements can be selected independently on the scan console for selected imaging of either breast (denoted BRL and BRR).

sequence optimization (spatial resolution, scan time and SNR). The patient is positioned prone on the breast coil. Obviously, it is important to register the patient in the correct position in the Patient Registration page. If the patient is registered in the head first/supine position, the position of the breasts will be transposed, i.e. the right breast will be shown as the left and vice-versa. The Siemens breast coil has lateral immobilization devices, which we use to minimize breast motion while scanning. It is important, however, not to compress the breast tissue. A 3-plane scout sequence of both breasts is performed with both coils activated. In our protocol, a pause step is programmed to remind the technologist to select the correct coil for unilateral imaging. The 3D shim option on the syngo MR systems very effectively suppresses fat signal in most patients when using fat-saturation or waterexcitation. Therefore, when the 3D slab is positioned, the sequence can be “Applied” and usually runs well automatically. Occasionally, fat suppression fails and the sequence must be adjusted manually and re-scanned. In the event that the fat suppression fails, it is most commonly due to incorrect center frequency (CF) selection by the system-specifically the CF of fat is selected rather than the CF of water. If the system incorrectly centers on the CF of fat, fat suppression will fail. It is crucial to evaluate the pre-contrast images for adequate fat suppression before proceeding to contrast injection and post-contrast scanning. (Fig. 1) Our breast MRI protocol is programmed such that the post-contrast slice position parameters are automatically copied from the pre-contrast sequence. It is important that the image positions match exactly. Obviously, patient compliance is important, and the patient should be carefully educated on the importance of remaining motionless and not shifting position between sequences.

Figure 1 Failed fat suppression (water excitation). Fat signal remains bright relative to the dark breast parenchyma.

High-resolution (non-dynamic) protocol
Most of our exams are performed in a high-resolution, non-dynamic mode. We acquire a non-spoiled, water excitation gradient echo sequence (FISP) with high spatial resolution in the sagittal plane. This is followed by rapid intravenous administration of contrast media, preferably via an antecubital vein. A spoiled, water excitation gradient echo sequence (FLASH) is immediately acquired. We routinely use 20 cc of Magnevist, injected at 2 cc/second. It is important to have the post-contrast sequence prepared in advance in order to minimize delay time between injection and image acquisition. The pre-contrast and post-contrast sequences are identical, except for the RF spoiler pulse applied on the post- contrast sequence (Table 1). The application of the RF spoiler pulse contributes to exam specificity. The non-spoiled FISP sequence is essentially T2*-weighted. Therefore, fluid-filled cysts exhibit high signal. The post contrast spoiled FLASH images are T1-weighted. The RF spoiling after contrast has two advantages: 1) The images are more sensitive to the gadolinium contrast, and 2) cysts appear dark and are easily distinguished from enhancing, bright lesions. (See Fig. 2) 63

Protocols and Techniques
Our exams are performed on the MAGNETOM Sonata and Symphony MR systems. Both are short-bore systems operating in the syngo MR platform. Sequences for both systems are shown and discussed below. Our exams are preferentially performed on the Sonata because the faster gradients allow for better

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Scans are performed in the sagittal plane. Phase encoding direction is adjusted to the head-to-foot direction for two reasons: 1) flow motion artifact arising from the heart, especially on post-contrast images, is displayed in the head-to-foot direction rather than anterior-toposterior and across the breast, and 2) this phase-encoding direction also prevents phase aliasing from the heart and posterior chest wall. We perform unilateral MRI breast exams. If the patient needs both breasts imaged (as dictated by the clinical situation), the exams are performed sequentially on separate days.

Sonata Sequence Imaging Plane Phase encoding direction Slices FOV Slice thickness TR TE Flip angle Averages Fat Suppression Frequency matrix Phase matrix Slice resolution Phase partial Fourier Slice partial Fourier Filter Slice mode Elliptical Receive bandwidth RF pulse type Gradient mode RF Spoiling (pre-Gad) RF Spoiling (post-Gad) Scan Time Gradient Echo Sagittal H>>F 128 180 x 180 1mm to 1.2mm 18 8.78 45 1 Water excitation 512 256 (50%) 50% Off Off Elliptical Interleaved On 130 Normal Fast Off (FISP) On (FLASH) 4:55

Symphony Ultra Gradient Echo Sagittal H>>F 128 180 x 180 1mm to 1.2mm 18 8.78 45 1 Water excitation 512 256 (50%) 50% Off Off Elliptical Interleaved On 220 Normal Normal Off (FISP) On (FLASH) 4:55

Table 1 High resolution pre- and post-contrast pulse sequences

Figure 2 Pre-contrast unspoiled gradient echo (FISP) left, and postcontrast spoiled gradient echo (FLASH) right. Cysts (arrow) are bright on the FISP images and dark on the FLASH images.

Figure 3 Pre-contrast unspoiled gradient echo (FISP) left, and postcontrast spoiled gradient echo (FLASH) right. Mass (arrow) enhances on postcontrast FLASH image.

The FOV, matrix, and slice thickness are optimized for high spatial resolution. Our default slice thickness is 1mm but we allow slightly thicker slices to accommodate larger breasts and to avoid aliasing artifact in the slice encoding direction. Additional slices would cost additional scan time in this 3D acquisition, so we do not increase the number of slices. A slice resolution of 50% (slice interpolation) reduces the scan time by half. The TR of the sequence is set to minimum. The TE is set to the minimum at which fat and water are in phase. A flip angle of 45 degrees gives us the best contrast between enhancing and non-enhancing tissues. At lower flip angles the normal breast parenchyma is brighter, somewhat lowering the conspicuity of abnormal enhancement.

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Dynamic Protocol The receive bandwidth of the sequence on the Symphony Ultra system is higher due to the faster gradients of the Sonata system. There is a 15% SNR penalty with the higher BW, but it is necessary to reduce scan time. If the patient has saline implants or no implants, we acquire the precontrast 3D FISP, ensure good image quality and fat suppression of the sequence, inject contrast, and scan the post-contrast sequence. The exam is usually complete in less than 20 minutes. If the patient does have silicone implants, an additional silicone suppressed pre-contrast sequence is acquired before the fat suppressed sequence, adding a little more than 5 minutes to the exam. Table 2 shows the pulse sequence parameters for the dynamic contrast enhanced sequence. The number of slices, slice thickness and matrix size show the compromise in spatial resolution necessary for the increased temporal resolution of the protocol. The reduced number of slices, increased TR and TE and increased BW of the Symphony system compared to the Sonata system are again due to the increased gradient performance of the Sonata. For the VIBE (Volume Interpolated Breath-hold Examination) pulse sequence, the fat saturation RF pulse is outside of the partitions loop, so it allows a shorter TR and TE than the water excitation scheme. [2] When dynamic information is important and contrast enhancement curves are requested, we scan the pre-contrast, high-resolution 3D FISP sequence first, followed by 1 precontrast measurement of the 3D VIBE. We then inject 20 cc of contrast at 2 cc/sec and immediately scan 5 measurements of the 3D VIBE. Finally, the high-resolution 3D FLASH
Sonata Sequence Imaging Plane Phase encoding direction Slices FOV Slice thickness TR TE Flip angle Averages Measurements Fat Suppression Frequency matrix Phase matrix Slice resolution Phase partial Fourier Slice partial Fourier Filter Slice mode Elliptical Receive bandwidth RF pulse type Gradient mode RF Spoiling Scan Time 3D VIBE Sagittal H>>F 64 180 x 180 1.8mm 6.12 3.1 12 1 5 Fat Saturation 256 246 (96%) 64% Off 6/8 Elliptical Interleaved On 260 Normal Fast On 1:00 Symphony Ultra 3D VIBE Sagittal H>>F 60 180 x 180 2mm 6.98 3.55 12 1 5 Fat Saturation 256 246 (96%) 64% Off 6/8 Elliptical Interleaved On 300 Normal Fast On 1:00

Table 2 Dynamic pulse sequence parameters

sequence is performed. The diagnostic value of the 3D FLASH post-contrast sequence is limited by the fact that it is acquired 5 minutes post contrast and significant lesion washout may have occurred.

[ 2 ] Personal correspondence with David Thomasson, Ph.D., MR Collaborations Manager, Siemens Medical Solutions

Acknowledgements
Special thanks goes to Dr Helmuth Schultze-Haakh and Dr. David Thomasson from Siemens for their assistance and support in sequence development.
* Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safety or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries where Siemens has systems. Siemens makes no claims as to the patient/staff safety, MR compatibility, or clinical capability of any of the non-Siemens devices included in the article. Before introduction of any device into the MR suite, the device should be inspected by qualified hospital personnel, and the non-magnetic properties of the device and its clinical operation in the magnetic field verified before it is used in a procedure. Use of these devices for animal or human procedures must comply with any applicable Governmental or local hospital safety and animal/ human studies committee’s requirements.

References
[ 1 ] Radiology Infonet “Update on Breast MRI” by Jeffrey C. Weinreb, MD, September 2001 (http://www.radinfonet.com/cme/ weinreb4/weinreb4.htm)

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Fetal MRI*: an Overview
Christine Harris, RT (R) (MR) Tamara Lee, BSRT (R) (MR) (CT) The Children's Hospital of Philadelphia biopsy; fetal echocardiography; genetic and prenatal counseling; expectant management; delivery and postnatal care; medical ethics panel review; open fetal surgery for rare and life-threatening conditions; and ultra-fast MR imaging. While ultrasound remains the standard for prenatal diagnosis and screening, we have found that it provides limited information for some types of fetal anomalies. Anatomic details that affect fetal prognosis and selection for prenatal therapy can often be difficult to image by sonographic methods. tially correctable condition or a diagnostic dilemma. Prenatal MRI is particularly helpful for improving anatomic definition, clarifying the diagnosis; identifying associated abnormalities, and is a valuable adjunct to ultrasound for prenatal diagnosis prior to fetal surgical intervention for selected life-threatening birth defects. With congenital diaphragmatic hernia (CDH), MRI shows the degree of liver impingement into the chest and the volume of lung mass present. It is hoped that these measured lung volumes will help in evaluating for pulmonary hypoplasia. With lung masses, MRI accurately distinguishes between cystic adenomatoid malformation and bronchopulmonary sequestration. For giant neck masses with potential airway obstruction, MRI permits differentiation of teratoma from cystic hygroma, and is more accurate than ultrasound in showing the impingement on the fetal airways and neck vessels. Information on the posterior fossa can be used to identify Dandy-Walker and Arnold-Chiari malformations. MRI has become an important tool in the diagnosis and management of fetal central nervous system abnormalities. It also contributes to our understanding of normal CNS development. Prenatal MRI is particularly helpful for: s Improving anatomic definition s Clarifying the diagnosis s Identifying associated abnormalities Fetal surgery is a rapidly evolving field, and new surgical protocols are continually being developed. Fetal surgery is employed for a variety of conditions, including spina bifida, hydrocephalus, and twin complications.

CHOP Fetal Program
The Children's Hospital of Philadelphia Fetal program is one of only two such centers in the US. The Fetal program began in 1985 under the direction of Dr. Adzick. The center’s task is to provide integrated multidisciplinary care for the mother carrying a fetus with a known genetic or anatomical birth defect that requires therapy before and after birth. The center brings a new perspective to the care of pregnant women by treating the fetus as a separate patient. The collaboration of numerous specialists enables us to provide high quality, state-of-the-art care to both patients (mother and child) together at one center. Comprehensive services range from prenatal evaluation and diagnosis to treatment, including invasive fetal therapy and open-heart surgery. Most perinatal outcomes can be improved through appropriate medical management. Accurate diagnosis of a fetal anomaly permits physicians and parents to choose a plan appropriately from among various treatment options. To date, the center for fetal diagnosis and treatment has received more than 600 referrals from 46 states and six countries. Comprehensive care includes: targeted sonographic evaluation of structural fetal anomalies; prenatal diagnostic procedures such as amniocentesis, fetal blood sampling, and fetal skin muscle 66

Fetal MRI
To improve our diagnostic capabilities, we are now using ultra-fast prenatal MRI, which provides superior tissue contrast in a variety of imaging planes regardless of fetal position. MRI using standard spinecho sequences has been used to determine fetal anatomy, but the quality and diagnostic utility of the scans have been limited by fetal motion. By contrast, ultra-fast MRI uses a variety of FDA-approved fast imaging sequences, which can be acquired sequentially, usually in less than one second, decreasing the chance that fetal movement which will affect the quality of the scan. Many attempts at imaging the fetus with MRI have been made since the mid-1980s, and until the development of ultra-fast imaging techniques, maternal sedation or fetal paralysis were employed to minimize the effects of motion on image quality. Patients selected for fetal MRI scanning are often candidates for fetal surgery and have undergone a multidisciplinary evaluation for a congenital anomaly that is a poten-

PEDIATRIC IMAGING

During the MRI exam, comfort is key for producing high quality images. Most patients experience pressure while lying on their backs. Semi oblique positioning may relieve some of this pressure. A small pillow under the back can also help. With these patients, claustrophobia and related anxiety are common. To alleviate this, try giving blow-by oxygen, play music or movies, etc.

Figure 1 Intrauterine twin gestation

Figure 2 Single fetus with omphalocele

Protocol
We utilize MAGNETOM Vision and Sonata 1.5T scanners. We use CP body array coil for better signal-tonoise. Currently we utilize the following pulse sequences as part of our protocol: HASTE (Half Fourier Single Shot Spin Echo), T2 gradient echo, Flash 2D, and EPI. These sequences vary in imaging time, which ranges between 3 to 35 ms each. Since fetal surgery may be part of the treatment plan and any additional diagnostic information might be useful for planning, it is generally our intent to provide a complete anatomical evaluation of the fetus. We will begin with the area of interest, then include as much of the fetal anatomy as possible, this being limited by fetal movement.

Figure 3 Single fetus with Hydrocephalus

Figure 4 Single fetus with MMC

The authors would like to thank the following:
The Fetal Center of Children’s Hospital of Philadelphia for allowing the authors to reproduce their written materials; in particular, Dr. Scott Adzik. The Radiology staff at CHOP: in particular, Drs. Larrisa Bilianuk, Anne Hubbard, and Robert Zimmerman, for being instrumental in developing our fetal imaging protocols; and the technical staff, for their patience while we developed our fetal protocols.

* The safety of imaging (fetuses, infants]) has not been established.

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Interpretation of Proton Spectra of Brain Tumors Using INTERPRET*
Peter Kreisler, Ph.D. Collaborations & Applications, MR Division, Siemens AG Medical Solutions, Erlangen Germany During the initial 2 years of the project, prototypes have been developed comprising: s Standardization of MRS scanning methods s A database (with approx. 500 patients with clinically proven data) s Pattern recognition methods MR spectroscopy allows non-invasive visualisation of the metabolic state of organs and pathologies in the human body. The technique is wellestablished for biochemical analysis. Excitingly, proton MR spectroscopy can be made available on clinical MR imaging scanners without any extra hardware required. However, since not all radiologists are also biochemists, the establishment of MR spectroscopy in clinical routine procedures is still on-going. The INTERPRET project aims at closing the gap between MR spectroscopy as research and as a clinically applied method. INTERPRET (International Network for Pattern Recognition of Tumors Using Magnetic Resonance) [1] is an R&D project funded by the European Commission intended to overcome these obstacles. Siemens is one of the industrial consortium partners supporting this project. The goal of this project is to develop a computer-based decision support tool, installed in hospital MRI centers, that will enable radiologists and other clinicians without special knowledge or expertise to diagnose and grade brain tumors routinely using magnetic resonance spectroscopy. s Graphical User Interface s Data Display, including discriminant score plots and colored nosologic images s Spectra and image data from the MR systems of different manufacturers, including Siemens.

The consortium partners in this EU project are:
s Universitat Autonòma de Barcelona (UAB), Spain s St. George’s Hospital Medical School, London, England s Institut de Diagnostic per la Image, Centre Bellvitge, Spain s Centre Diagnòstic Pedrables, Spain s Université Joseph Fourier, Grenoble, France s University Medical Center Nijmegen, Netherlands s Stichting Katholieke Universiteit Nijmegen, Netherlands

This new software tool assists in the interpretation of clinical spectra. The patient data in question are compared with data in a data base. They are analyzed using pattern recognition techniques. Discriminant scores for certain types of tissue in the voxel of interest are calculated and displayed. Pattern recognition techniques are applied to CSI-data as well, and the results can also be transferred into so-called nosologic images showing different tissue types in different colors. A prototype of this software was shown at the Siemens booth at this year’s ISMRM meeting in Honolulu/ Hawaii. The overall feedback from radiologists and physicists collected during this meeting was very positive, indicating that this approach is promising and should be continued. A final product decision has not been made so far. For further details, please look at the INTERPRET home page http://carbon.uab.es/INTERPRET/

s University of Sussex, Brighton, England s PRAXIM, Sarl , France s Siemens AG, Medical Solutions, Erlangen, Germany

* “The information about this product is preliminary. The product is under development and is not commercially available in the U.S., and its future availability cannot be ensured.”

[ 1 ] EU-Project: Information Societies Technology; IST – 1999 – 10310; Project duration January 1st, 2000-December 31st, 2002 Project coordinator: Carles Arús, Universitat Autonòma de Barcelona (UAB), Spain e-mail: Carles.Arus@uab.es

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SPECTROSCOPY

Figure 1 Typical spectra of various brain tumors

Figure 2 Screen layout of INTERPRET prototype showing spectra on the right side and the 'discriminant score' plot on the left. The new case (yellow dot) appears in the plot on the left and can be compared with the spectral pattern of close neighbors on the right.

Figure 3 Example of a CSI result with colored clusters, calculated on the base of the spectral data using a so-called “mixed modeling approach” for pattern recognition. The CSI data are achieved with a short TE STEAM sequence.

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MR Imaging of the Knee in Ironman Triathlon Athletes
Frank G. Shellock, Ph.D. For triathletes older than age 35, who have participated in this sport for several years, the associated repetitive musculoskeletal loads may have an adverse, cumulative effect on the joints. The knee is a critical musculoskeletal anatomic site for competitive and recreational athletes. To date, there has been no research conducted to evaluate the knees of triathletes for the prevalence of meniscal abnormalities, ligament abnormalities, articular cartilage defects, hematopoietic bone marrow hyperplasia, bone contusions, or other conditions. Notably, it is unknown if older triathletes have a greater prevalence of certain conditions compared to other athlete populations or to non-athlete subjects. Additionally, the long-term effects on the knee of training and competing as a triathlete, particularly at the Ironman triathlon level, have not been determined. In a recent study presented by Dr. Frank Shellock at the 2002 Annual Meeting of the International Society for Magnetic Resonance in Medicine, a Siemens Symphony MR system at the North Hawaii Community Hospital was used to evaluate the knees of 29 older Ironman triathletes to determine the prevalence of abnormal findings. The MR examinations were conducted prior to competition or heavy training, or no sooner than 48 hours afterwards, to prevent exerciseinduced changes from affecting interpretation of the MR findings. The knee was positioned in a transmitreceive extremity coil, at an external rotation of approximately 15 to 20˚. A routine MR imaging protocol of the knee was performed, which included the following sequences: axial, T2-weighted SE; sagittal, proton density-weighted; sagittal, T2-weighted TSE; coronal, 70 proton density-weighted TSE with fat saturation, and coronal, inversion recovery. The results showed that the spectrum of abnormal MR findings in older triathletes was similar to that of agerelated changes previously reported for other athletes and non-athletes. However, there appeared to be an unusually high prevalence of joint effusions in this older athletic population. (Fig. 2) The overall results of this research suggest that functional adaptations may occur in the tissues of the triathlete knee. Importantly, these findings have important implications for the diagnostic use of MR imaging of the knee in this high endurance, athlete population. (Fig. 3) The MAGNETOM Symphony at North Hawaii Community Hospital (Fig. 4, Fig. 5, Fig. 6) will be used for future research investigations to be performed by Drs. Hiller, Ainge, Brown, and Shellock on Ironman triathletes, including assessments of the shoulder and patellofemoral joints utilizing kinematic (moving) MRI techniques.

Triathlon competitions involve swimming, bicycling, and running over various distances and under a variety of technical conditions. The Ironman Triathlon, comprising a 2.4-mile swim, a 112-mile bike race, and 26.2-mile run, is one of the best-known triathlon events, and is held annually on the Big Island of Hawaii. (Fig. 1)

Figure 1

[ 1 ] Frank G. Shellock, Ph.D., W. Douglas B. Hiller, M.D., George R. Ainge, M.D., David W. Brown, M.D., Laura Dierenfield, B.S. “Knees of Ironman Triathletes: MR Imaging Assessment of Older (>35 Years Old) Competitors”. Proc. Intl. Soc. Mag. Reson. Med. 10 (2002)

ORTHOPEDICS

Figure 3 Hematopoietic hyperplasia in ironman athlete

Figure 4 North Hawaii Community Hospital (NHCH) is a full-service, acute care medical center located on the Big Island of Hawaii. Opened in 1996, NHCH serves a population of over 30,000 from the Big Island and beyond.

a)

Figure 2 Bone contusion and joint effusion in ironman athletes.

Figure 5 MAGNETOM Symphony at the North Hawaii Community Hospital Imaging Pavilion. b) Figure 6 a) W. Douglas Hiller, M.D. Head of Ironman Research b) Technologists Roy Young (left) and Kirk Smith.

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MAGNETOM FLASH 3

Magnetic Resonance Imaging of the Wrist
Bill J. Leon R.T. (R ) (MR) From the Department of Diagnostic Radiology Magnetic Resonance Imaging Center Health South Doctors’ Hospital, 5000 University Drive, Coral Gables, Fl 33146, USA T2 weighted images are of low sensitivity but high specificity. This means that we may not detect tendinitis, but we are able to visualize partial or total tears of a tendon. Gradient echo images T1 or T2* may be oversensitive to pathology. This means that whilst we cannot reliably “call” specific pathology with just these types of image, however, its utilization in addition to other pulse sequences has proven very valuable especially when imaging articular cartilage. Coils. Small Circular Polarized Flex Coil, Dedicated Phased Array Wrist Coil. Patient supine. Arm by the side. Positioning. The patient is asked to exercise the wrist using rotary motions and weight bearing if possible, including push-ups, ten to fifteen minutes prior to MRI in order to increase the amount of fluid in the wrist and increase the visibility of ligament tears. The patient is positioned supine with the wrist by the side. A small circular polarized flexible coil is utilized wrapped around the wrist or the new phased array dedicated wrist coil. Any way to increase patient comfort should be attempted as motionless images are imperative for accurate diagnosis. Accessories. Foam pads, towels, tape. Figure 2 Positioning with Wrist Phased Array Coil

Imaging “small joints” is not an easy task to accomplish, primarily because to visualize small structures there is a need for high resolution images. High Resolution MR is defined as small pixels obtained with high matrices (192 x 256 or higher), small FOV’s (six to ten centimeters), and thin slices (two to four millimeters). Images with small pixels present an obvious problem of poor image quality due to low SNR. There needs to be an adjustment to either technical parameters or selection of coil and/or coil-part positioning in order to improve the SNR of these images. We can then redefine our statement: Small joint imaging requires high resolution with good signal-tonoise. A combination of pulse sequences in multiple planes is necessary when designing protocols. These techniques must be tailored to specific pathology. With a variety of pulse sequences, visualization of anatomic structures such as tendons, ligaments is possible. T1 weighted images present high sensitivity and low specificity. This means that if in a T1 image a tendon has increased signal intensity (gray) and normal tendon is low signal intensity (black), there may be inflammation (tendinitis), a partial tear, or a complete tear. Therefore, we can detect pathology but we cannot tell specifically how bad the injury is. 72

Figure 1 Positioning with CP-Flex Small Coil

ORTHOPEDICS

Plane 3d gre cor 2d gre cor stir cor tse Ax/sag tse ax/sag se t1 sag se t1 c/a/s FS

Sequence fi3d_21rb33.wkc (Flip Angle: 7 deg) fl2d_22rb44.wkc (Flip Angle: 20 deg) tirm7_29b130.ykc Tse7_45b130.ykc Tse5_17b98_102b98.ykc se_20b65.wkc se_20b65.wkc

TE 21 22 29 45 17/98 20 20

TR 48 660 3395 4000 4000 545 741

SL 26 15 13 23 23 17 13

Th/Gp 1.3/0 2/0.1 3/0.1 3/0.1 3/0.1 3/0.1 2/0.1

Mx 192x256 200x256 196x256 224x256 256x512 256x512 192x256

Acq 1 2 3 2 1 1 2

FOV 80 90 90 90 88 90 70

Time 8:01 8:50 8:34 3:49 7:01 4:42 9:32

Table 1 Parameters (MAGNETOM Vision)

Protocol:
In general, wrist protocols include all three planes: coronals, sagittals and axial images. 1. Select one type of coronals: a. Gradient echo 3D T2* b. 2D gradient echo T2* c. Spinecho PD/T2 d. Turbo spinecho PD/T2 2. Turbo STIR coronal 3. TSE PD transverse 4. SE T1 sagittal Optional: 5. Post-arthro-Gd + T1 coronal high resolution 6. Post-arthro-Gd + T1 coronal, transverse fatsat 7. Post-arthro-Gd + 3D gradient echo coronal Figure 4 Set-up of axial slices Figure 5 Set-up of sagittal slices Figure 3 Set-Up of coronal slices

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MAGNETOM FLASH 3

Figure 6 Visualization of TFCC and their pathologies

Clinically, wrist imaging with MR is done to detect:
1. Ligament integrity a. Scapho-Lunate (S-L) b. Luno-Triquetral (L-T) 2. Triangular fibrocartilage tears 3. Articular cartilage thinning and defects 4. Bone marrow disorders a. AVN of lunate (Kienbock’s disease) b. AVN of scaphoid (Preiser’s disease) 5. Flexor/extensor tendons pathology a. Tendinitis (inflammation of tendons) b. Tenosynovitis (inflammation of tendon sheathes) 6. To a lesser extent carpal tunnel syndrome a. Inflammation of median nerve b. Compression of median nerve by masses, or tendon pathology. SE T2 cor SE PD cor SE T1 cor arthro gd+ 3D gre T2* coronal Turbo STIR coronal SE T1 cor postarthro Gd+ 3D gre T2* coronal Turbo STIR coronal SE T1 cor FS Gd+

In order to detect this array of pathologies, several diagnostic procedures are done: three phase arthrogram (ligaments, TFCC), nuclear medicine bone scans (AVN), radiographs, nerve conducting exams (median nerve): each of these has some degree of false negatives. MR in combination with an intra-articular injection of gadolinium may be the new gold standard of wrist imaging to diagnose intracarpal ligaments and triangular fibrocartilage tears.

3D gre T2*

SE T1 cor arthro gd+

SE T1 cor fs arthro gd+

TFCC (Triangular Fibro-Cartilage Complex) and/or Ligaments
s 3DGRE T2* coronal s 2D GRE T2* coronal s Spinecho PD/T2 coronal s STIR coronal s Post-Gadolinium / Arthrogram SE T1 FS Coronal s Post-Gadolinium / Arthrogram SE T1 non FS Coronal

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ORTHOPEDICS

Figure 7 Contusions & fractures

Turbo STIR cor

SE T1 cor

SE T1 sag

Turbo STIR cor

Turbo STIR axi

SE T1 axi

Bone Marrow / Contusions, Fractures:
s STIR coronal or TSE T2 FS coronal s SE T1 high resolution cor, sag and axi

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MAGNETOM FLASH 3

MR Imaging of Non-Displaced Fracture of the Humerus
Mark Robbin, M.D. Pete Young, M.D. Jonathan S. Lewin, M.D. University Hospitals of Cleveland Case Western Reserve University, Cleveland, Ohio, USA

Results & Discussion
Coronal fast spin echo proton density (Fig. 1) and fast spin echo T2 weighted coronal with fat saturation (Fig. 2) images are shown first. The coronal proton density weighted image (Fig. 1) demonstrates an impaction fracture in the greater tuberosity region of the proximal humerus. There is abnormal signal in the distal supraspinatus tendon. On the coronal fast spin echo T2 weighted image with fat saturation (Fig. 2) there is fluid signal with surrounding edema in the supraspinatus tendon, consistent with an articular surface partial thickness tear with overlying intact fibers. There is a bursitis in the adjacent subacromial-subdeltoid bursa. The increased signal in the greater tuberosity of the humerus is due to a bone bruise and edema surrounding the impaction fracture. The coronal fast spin echo T2 weighted image with fat saturation (Fig. 3) and sagittal fast spin echo T2 image with fat saturation (Fig. 4) demonstrate the undersurface tear of the supraspinatus with surrounding bursitis in the subacromial-subdeltoid bursa. The extensive marrow abnormality in the greater tuberosity is due to the impaction fracture with surrounding bone bruise. The sagittal T1 weighted image (Fig. 5) demonstrates the extensive greater tuberosity fracture. This fracture was not visible on prior radiographs. MR imaging is extremely sensitive for non-displaced fractures and bone bruises. Impaction fractures of the greater tuberosity region are commonly associated with partial and full thickness rotator cuff tears. These are best diagnosed and characterized with MR imaging.

Figure 1

Clinical Presentation
The patient was a 74-year-old male who sustained a fall on his left shoulder and presented with left shoulder pain. An X-ray examination of his left shoulder was unremarkable. An MR study was performed on a Symphony Quantum system with shoulder array coil.

Figure 2

Figure 3

Figure 4

Figure 5

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The MAGNETOM Family Leading the Innovations in MR

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A91100-M-Z733-1-7600

When the choice is yours and you have gained a certain perspective on MR systems, your decision will be based on what‘s best for your patients and your business:

The MAGNETOM Open Class Open to everyone • MAGNETOM Concerto • MAGNETOM Rhapsody The MAGNETOM Ultra Class

The MAGNETOM® Maestro Class A new degree of perfection • MAGNETOM Harmony 1T • MAGNETOM Symphony 1.5 T • MAGNETOM Sonata 1.5 T

3T & beyond • MAGNETOM Allegra – the brain scanner • MAGNETOM Trio – the whole body scanner

MAGNETOM FLASH 3

Eight RF Receiver Channels and the Integrated Panoramic Array (IPA™)
Daniel S. Grosu, M.D. Siemens Solutions USA, Inc. Advances in coil technology eventually led to the development of the circularly polarized (CP) coil, consisting of two independent LP elements that individually detect the MR signal. The signals from the two elements were merged into a single receiver channel, as before. This resulted in SNR gains of up to 40 % and represented a major step forward. What was needed in order to unleash the full potential of MR imaging, however, was a solution allowing coverage of large anatomical areas with the image quality typical of smaller coils. This meant expanding the number of coil elements, by using CP array coils, and the number of RF receiver channels that could be used simultaneously to acquire an image. Special software was also required to produce artifact-free images from the multi-channel data.

Pushing the Limits of MRI: Multi-Channel Technology
In 1997, Siemens ushered in a new era in MR imaging when it received FDA clearance for eight independent, high-bandwidth (1MHz) RF receiver channels for its 1.0T and 1.5T systems. Each channel has its own analog-to-digital converter (ADC), which captures the MR signal with a high dynamic range. This technology forms the foundation for Siemens’ revolutionary IPA (Integrated Panoramic Array) concept, which enables the simultaneous use of multiple-coil elements for MR imaging. Eight RF receiver channels and IPA have been commercially available on MAGNETOM scanners for more than two years, and more than 2,000 systems featuring this technology have been installed to date worldwide*. The IPA concept leverages Siemens’ traditional strengths in MR coil technology, as the vast majority of current Siemens MR coils are IPAcompatible. These are time-saving “no-tune” coils, and feature integrated low-noise preamplifiers for SNR optimization. Up to 16 CP coil elements (32 LP elements), from up to 4 different IPA coils, can be used simultaneously to create customized

Multi-channel technology has revolutionized MR imaging over the last few years, and Siemens has been the clear leader with its IPA (Integrated Panoramic Array) concept and eight independent RF receiver channels. Most current Siemens MR coils are IPA-compatible, and IPA allows users to create customized arrays by combining individual elements from different coils. This capability is unique to Siemens. Multi-channel imaging with IPA offers unprecedented advantages in terms of speed, diagnostic accuracy, and patient comfort.

Once Upon a Time: A Brief History
In the early days of MR imaging, the MR signal was detected by one manually-tuned, linearly polarized (LP) coil, and conveyed to the image reconstruction computer through one low-bandwidth RF receiver channel. In order to image a large field of view (FoV), the receiving coil had to be correspondingly large. The signal-to-noise ratio (SNR), and therefore the image quality achievable in this scenario, were modest and long imaging times were the norm.

Figure 1 Schematic representation of various CP array coils that can be combined using the IPA coil concept, for exceptional flexibility in anatomical coverage. 78

TECHNOLOGY CORNER

Figure 2 Screen capture from syngo MR 2002B showing five active elements (red vertical bars) in direct relation to the anatomy on two scout images. The topmost element (partially visible in the sagittal image) is the lower segment of the CP Head Array. The other four elements belong to the CP Spine Array. Coil elements can be selected individually, and the table can be moved remotely, via software on the operator console outside the scanner room.

arrays for a wide variety of imaging applications. (Fig. 1) Importantly, the CP Spine Array (an array of 6 CP elements, which forms the backbone of the IPA coil concept) and the lower part of the CP Head Array, remain on the patient table (Fig. 2) in more than 95% of cases. This capability to combine elements from different coils is unique to Siemens. It offers not only unprecedented setup flexibility but also considerable time savings. Patient setup time is dramatically reduced with IPA because the need for coil changes is virtually eliminated, and patient repositioning during the MR exam is no longer required. The ability to do all this with existing coils is a very important consideration: all other currently available* multi-channel offerings on the market do not permit combinations of elements from different coils, and require the purchase of new, dedicated CP array coils. Moreover, IPA coils are compatible with Siemens’ iPAT (integrated Parallel Acquisition Techniques), for the ultimate in MR imaging speed. (Fig. 3)

Figure 3 Three-station, one-setup, contrastenhanced MRA from the top of the aortic arch to the feet, showing extensive vascular disease in the left leg. Centric elliptical acquisition with IPA using various iPAT factors. Note the excellent visual continuity from one acquisition to the next. Aortic arch to iliac arteries: PAT factor 3 (384 matrix, TA = 14 s); Upper legs: PAT factor 2 (512 matrix, TA = 11 s); Lower legs: no iPAT (512 matrix, TA = 40 s). Coils / elements used: Upper Station: CP Body Array (2 elements) + CP Body Array Extender (2 elements) + CP Spine Array (4 lower elements). Middle Station: CP Peripheral Angio Array (4 upper elements); Lower Station: CP Peripheral Angio Array (4 lower elements).

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MAGNETOM FLASH 3

Further enhancing the capabilities of IPA is Integrated Panoramic Positioning (IPP), which enables remote selection of individual CP elements and remote control of table movement from the operator console using an intuitive graphical interface built into the syngo MR software (Fig. 2). Imaging with IPA and IPP affords the largest combined FoV in the industry: 150cm (5ft) of contiguous coverage. The entire central nervous system (CNS) can be scanned, for example (Fig. 4), with only one setup – a Siemens exclusive!

The Benefits
The extensive capabilities of IPA and IPP, and the large selection of IPA coils currently available, allow for an almost limitless range of applications. The versatility made possible by this technology is unequalled in the industry, and offers exceptional benefits for both clinical and research purposes: s Outstanding image quality can be achieved because of the close proximity of CP coil elements to the relevant anatomy. This makes highSNR acquisitions possible even with large fields of view (Fig. 5, Fig. 6). Customized arrays, created by combining coil elements, optimize anatomical coverage for challenging applications such as brachial plexus (Fig. 7) or prostate (Fig. 8) imaging. A distinct advantage of multi-station acquisitions with IPA is the ability to visualize large anatomical areas at a glance while benefiting from optimized image quality at each station (Fig. 3, Fig. 4).

Figure 4 Two-station, one-setup IPA exam covering the entire CNS. Each acquisition has a 512 matrix and a 450 mm FoV. Note the excellent visual continuity between the two acquisitions. Coils / elements used: CP Head Array + CP Neck Array (2 elements) + CP Spine Array

Figure 5 Large field-of-view (500 mm) IPA exam with respiratory triggering, showing extensive lung cancer. Coils / elements used: CP Body Array (2 elements) + CP Body Array Extender (2 elements) + CP Spine Array (4 upper elements) 80

TECHNOLOGY CORNER

Figure 6 Contrast-enhanced MRA with IPA. FoV = 400 mm (MAGNETOM Sonata). Coils / elements used: CP Body Array (2 elements) + CP Body Array Extender (2 elements) + CP Spine Array (4 middle elements)

s Total imaging time is reduced significantly because coil setup is performed only once, at the beginning of the study. During the examination, remote selection of coil elements and remote control of table movement virtually eliminate the need for coil changes and patient repositioning during the exam. Table movement can even be automatized (built into the protocol) for multistation studies! s This technology is extremely easy to use. The CP Spine Array Coil and the lower segment of the CP Head Array Coil are already fully integrated into the tabletop. Additional coils can be easily connected to ergonomically positioned sockets, and individual coil elements can be subsequently activated using an intuitive software interface at the MR console, outside the scanner room. Indeed, after the initial patient positioning and coil setup, the operator’s presence in the scanner room is not required until the very end of the examination – even with multi-station studies! s Diagnostic accuracy, workflow, and patient comfort are enhanced as a result.

Figure 7 Brachial plexus imaging with IPA. Coils / elements used: CP Neck Array (2 elements) + CP Body Array (2 elements) + CP Spine Array (3 upper elements)

Figure 9 Contrast-enhanced 3D MRA on a Siemens MAGNETOM Trio using a dedicated 8-channel neurovascular coil. Voxel size = 0.6 mm x 0.8 mm x 0.9 mm. TA = 22 s. Courtesy of Gregory Sorensen, M.D., Massachusetts General Hospital, Boston, USA

The Bottom Line
Siemens is the industry leader in multi-channel MR imaging, and has been offering eight high-bandwidth RF receiver channels on its MAGNETOM systems for more than two years. This technology forms the foundation for the revolutionary IPA coil concept, which greatly expands the range of applications on Siemens MR scanners. IPA offers benefits in terms of diagnostic utility, productivity, patient comfort, and investment security that are unmatched in the industry.

Multi-Channel Technology on the MAGNETOM Trio
Siemens has successfully integrated multi-channel technology into its whole-body 3T system, and the MAGNETOM Trio offers eight independent RF receiver channels as standard equipment. This 3D MRA from the top of the aortic arch to the circle of Willis (Fig. 9) was acquired using an FDA-approved 8-channel dedicated neurovascular coil.

Figure 8 Prostate cancer imaging with IPA. FoV = 200 mm, Matrix = 512. Courtesy of Dr. Carl Engelhard, Martha-Maria Hospital, Nürnberg, Germany Coils / elements used: CP Body Array (2 elements) + CP Spine Array (2 lower elements) + Endorectal coil

This USA Instruments coil was FDA approved in July 2002 for use with the Siemens MAGNETOM Trio.
1

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MAGNETOM FLASH 3

Top Ten syngo Questions
The top 10 questions are derived from you, our customers. Telephone calls initiated to the Uptime Service Center in Cary, NC are tracked daily. The questions listed below were the most frequently asked questions regarding 2002A syngo. We encourage you to call the Uptime Service Center with your questions at 800-888-SIEMens (7436) and speak live with one of our MR Application Specialists. draw a contour around the vessels with the mouse key pressed. Complete the freehand VOI with a double click. Click on the Keep icon. You can change orientations and then Free Draw around the anatomy again. Click the Keep icon. Return to Reference mode. Select the image plane you want to plan the rotations on. Note if you have a sagittal (lateral) image, click directly on the green axis line and green arrow intersection that comes up. Click on the Radial Ranges icon. Plan your rotation by dragging the lines around the center. Type in the number of slices. Click on the Start button. Click on the Save As icon. Name the Comment, which will appear on each image. Name the series which will appear on the Patient Browser.

?How do I carry out 4.
a Daily QA?

!

?How do I edit or correct 1.
the patient text?

!

Place the red service sponge in the head coil. It will be labeled top end toward the magnet and bottom end out of the magnet. Place the large cylinder phantom in the sponge and center to the coil. Position the phantom with the “chin” up. There is a little bump on one end of the phantom. Localize to the center of the phantom in the center of the coil and move to isocenter. From the Exam Card: Go to Options, click on Customer QA. Select the Head Array. You will see a couple of messages such as “Initializing” and “Done”. Then click on the little box next to SN Dip. Click on the Start. Phantom Set-up Display Window. Click OK. You will see a message “Running”. This scan will take about 2 minutes. Then the message “Done”. Then hit Ctrl, Esc. Go to Favorites, then Daily QA. Double click on the date to see the results.

Make sure the patient is not protected and not open in any of the cards. Go to your main menu bar, select Patient, select Browser. In patient browser, select patient, study, series, or images that you want to correct. In the patient browser menu bar, select Edit, select Correct. Correct or add to the selected data. Enter your name under Modifier’s name. Click onto OK to save the new data.

?
3. How do I carry out a manual Fat Sat?

!
When in the Protocol, select Fatsat. Make sure Standard shim is selected on your System Card. You can adjust the volume down to the skin surface (green box; Position Toolbar-Adjust Volume On. Do not close the protocol. Select Options, Select Adjustments. Select the Frequency Card, click on GO. Strive to get 0 Hz. difference (+ or –1 is OK). Select the 3D Shim Card. Select Standard, select Low. Hit Measure. Hit Calculate. Hit Apply. Select the Frequency Card, click on Go, until you get zero once again on the Hz. Difference. Close the Adjust platform. Hit Apply to begin the measurement.

?How do I perform an MIP 2.
a study?

?How do I manually adjust 5.
a sequence?

!

On the Patient Browser, choose the series of the patient that you want to MIP. Go to Menu bar, select Patient, select 3D MIP. Go to the 3D Task Card. Choose the VOI. Reduce the volume of interest box. You can draw a freehand VOI around the anatomy by clicking on Draw New icon. Click on the starting point of the freehand VOI in the top right segment and 82

!

Leave the protocol open. Go up to Options, click on Adjustment. Click the Transmitter card of the adjustment dialog box into the foreground. Click on the button Go. Successful transmitter adjustment is reported by the entry Y in the last table column and by the message Adjustment finished in the status bar.

TECHNOLOGY CORNER

If the entry N is displayed in the last table column, you have to repeat the last step until the entry Y is displayed. Click the Frequency card of the adjustment dialog box into the foreground. Click on the button Go. Successful frequency adjustment is reported by the entry Y. The last table column and by the message Adjustment finished in the status bar. If the entry N is displayed in the last table column, you have to repeat the last step until the entry Y is displayed. Close the adjustment dialog box. Start scanning the protocol by clicking on Apply in the program control.

?How do I retrieve a 8.
patient’s study from a prior CD?

!

Put the prior CD in the CD reader tray. Go to your main menu bar, click on Patient, select Browser. In the patient browser, click on the CD Reader. Then select the patient that you want to retrieve. Go to Transfer, select Import.

the “across series” mode. You can select an image number in the Test Image drop-down. Click on Test to see the subtracted image. This allows you to confirm that you have the two series in the correct order for subtraction. Enter a name for the new series in the Results Series Description box. Click OK. You will see the Reconstruction icon in the lower right corner of the screen during the subtraction process. If you click on the Reconstruction icon, you will get Calculation Status window; where you can see the Subtraction taking place as well as the status of the calculation. The new series will be in the Patient Browser. You can open the Patient Browser to see the series or click on the Refresh icon if the Patient Browser is still open.

?How do I select another 9.
camera to route my films to?
Go to your Filming Task Card. Click the Camera Subtask card into the foreground. Select a camera from the list. This selection list contains all the cameras connected to your system. The newly selected camera is used as the default camera, which is used until you select another one.

?Which one is the in 6.
phase and out of phase?

!

!

The lower TE is the out of phase. The higher TE is the in phase. You may also hold your mouse cursor behind the TE in the Exam Card and a tool tip will show you that.

?What is the table weight ? 7. 10. How do I do subtraclimit for our MR System? tion?

!

The MAGNETOM Harmony, Symphony, Sonata and Concerto MR Systems have the table weight limit of 440 lbs. (200 kg).

!

Open the Patient Browser. Using the Ctrl key, select the two series. Click on Evaluation from the drop-down menu. Select Dynamic Analysis. Select Subtraction. The two series will be displayed in the Operands window. You will want the post-gad series to be the first one listed. Click on Exchange to switch the series. This will automatically come up in 83

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MAGNETOM FLASH 3

Invitation from the Organizational Committee to the MAGNETOM World
PD Dr. Stefan Schoenberg Dr. Christoph Zech Dr. Konstantin Nikolaou Instituts für Klinische Radiologie Klinikum der Ludwig-MaximiliansUniversität München

MR 2003: MRI – reinventing its novelty
Whilst we would not presume to anticipate what the speakers at our symposium will have to say, we really believe that MRI remains the standardbearer for the future. Although some other efficient imaging methods are available, MRI remains the first choice in many fields of indications, such as the assessment of cardiac function, MR angiography and sophisticated examinations of the brain. Due to the steadily growing interest in the symposium, we have been encouraged to maintain the previous format of scientific sessions in the morning and afternoon schedules. Positive feedback has also led to the traditional tutorials taking place as before, along with the interactive film reading in between the scientific sessions. To emphasize the close relationship between technical advances and clinical practice even further, we have chosen special keytopics, including presentations of diagnostic strategies and convincing exam results. The special interest session “Meet the expert” has been included in the program for the first time. In four different sessions, small groups will have the opportunity to discuss interesting cases of everyday clinical work with proven experts. Updated information on the congress program and online registration is available on the website www.mr2003.org. It is again planned to have a simultaneous GermanEnglish translation, although the MR courses on Tuesday and Wednesday, January 28th and 29th, 2003, will be held in German only. We are confident that the program will be exciting to all practising radiologists and are looking forward to welcoming you in the winter wonderland of Garmisch.

Scientific committee

We are proud to announce the forthcoming international MRI symposium – “MR 2003” – which is already the tenth such symposium, to be held in the beautiful resort of GarmischPartenkirchen. The meeting, established by Professors Lissner, Doppman and Margulis, has become a permanent fixture in the calendar, offering an important opportunity to learn about the current state-of-the-art techniques and new trends in magnetic resonance imaging (MRI). We have experienced a significant number of new developments over the years: wide-ranging technical improvements, faster pulse sequences, new methods of examination. MRI has kept at the head of the field by reinventing its novelty over the twenty years since its introduction into the clinical practice, even though other methods of examination, especially multidetector CT and PET-CT, have become established as efficient alternatives. For this reason, we feel more than justified in holding our upcoming MRI symposium under the motto:

Prof. Hedvig Hricak, M.D. Ph.D. Chairman, Department of Radiology Memorial Sloan-Kettering Cancer Center, New York

Prof. Dr. Dr. h.c. Maximilian F. Reiser Direktor des Instituts für Klinische Radiologie Klinikum der Ludwig-MaximiliansUniversität München

84

EVENTS

Organizational committee:

Invited US-Faculty – preliminary program (excerpt): H. Hricak “Molecular imaging through the eyes of a clinician: Does it have impact on clinical radiology?” and “Imaging of prostate cancer: Impact on patient management and outcome” Lecture from his book “Be in charge” (Original title: “Chiefs don’t cry”) or “Advances in MR contrast agents” (To be announced) “MRI of cartilage in health and disease” “Sports-related injuries: Linking MR imaging findings to clinical relevance” and “Sports-related injuries of the shoulder” “Stroke imaging: What to do when?” and “Differential diagnosis of brain tumors” “MRA - first diagnostic choice for evaluation of all vascular territories?” and “Imaging of the pulmonary arteries – is there a role for MRI?” “High field MRI: Is there a clinical benefit?” and “Interventional MRA” “MRI for detection of early invasive breast cancer and biopsy” “MR angiography and preoperative evaluation for laparoscopic donor nephrectomy” “Staging of overian and cervical cancer” “Peripheral MRA: Answering the surgeon’s and interventionalist’s questions”

A.R. Margulis

H. Genant D. Resnick PD Dr. Stefan Schoenberg Institut für Klinische Radiologie Klinikum der Ludwig-MaximiliansUniversität München W. Kucharczyk T. Grist

G. Glazer E. Morris S. Ascher Dr. Christoph Zech Institut für Klinische Radiologie Klinikum der Ludwig-MaximiliansUniversität München N. Rofsky

Dr. Konstantin Nikolaou Institut für Klinische Radiologie Klinikum der Ludwig-MaximiliansUniversität München 85

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MAGNETOM FLASH 3

The Era of Whole Body MRI
HC Cheng, M.D., Ph.D., SC Ko, M.D., SY Chang, M.D. VGH-HT Imaging Center, Taipei Veterans General Hospital Department of Radiology

Materials and Methods
MRI was performed on a 1.5T clinical scanner with IPATM hardware (MAGNETOM Sonata, Siemens, Erlangen).

Protocols
We provide our clients with the following five different packages: 1. Tumor: From head, neck, chest, abdomen, pelvis and whole spine with three orthogonal sections for each region, including more than 35 sequences and over 400 images. Ultrasound is supplementary for the thyroid gland, and the whole abdomen for complaints such as gallstones, renal stones and vesicle stones. We have carried out 1,978 cases (M:F = 60:40; mean age 52 years old); 2. Stroke: Both brain MRA, and contrast enhanced carotid MRA. Brain perfusion study is reserved for assessing the significance of intracranial stenosis. Carotid Doppler is routinely applied for the plaque characterization and hemodynamic assessment. We have carried out 1,253 cases (M:F = 71:29; mean age: 54 years old); 3. Cardiac: LV functional assessment, valvular function, myocardial perfusion (Dipyridamole) and viability. We have carried out 468 cases (M:F = 75: 25; mean age: 56 years old) 4. Breast: Both 3D dynamic fat saturation breast MR and delay enhanced 3D high resolution breast MR. Breast US is also routinely applied for the different tissue characterization and the guidance of aspiration or biopsy. We have carried out 323 cases screening and 25 cases biopsy (mean age: 51 years old) 5. Whole body MRA: Using AngioSurf for five steps contrast enhanced MRA.

Patient selection Introduction:
There are several misconceptions about the application of MRI, such as a longer examination time, and limited examination regions. With the development of ultra-fast gradients and rapid sequences, however, the examination time is significantly reduced. Most routine clinical examinations can be completed within 20-30 minutes, some even within1015 minutes. In certain clinical situations, including cancer staging, a whole body examination is necessary for the comprehensive study. Nuclear medicine or spiral CT seems more easily to cover the large area for the extension of diseases. The preliminary results of whole body MRI for breast cancer staging seem a convenient and cost-effective method [1, 2]. Those two reports concerned only applied body coil with single shot axial images. With the advance of technology (integrated panoramic array coil, IPA), patients do not have to move at all. It only takes four coil replacements to cover from head and neck, chest, abdomen, to pelvis. The CP Spine Array coil always remains on the table for the combination of CP Neck Array coil, CP Body Array coil or large flexible coil. This friendly design can accelerate patient set-up time dramatically, and provide higher signal to noise level than the aforementioned body coil approach. The aim was to implement the new protocol for the whole body MRI screening, not only for the staging of known malignancy but also for the health screening of occult cancers. 86 While we are open for self-referral, we encourage people who have specific complaints to visit their family physicians or specialists to solve their problems. Anyone that has received a diagnosis will be excluded from our study. Cancer patients under complete remission are accepted within the asymptomatic group but not within the healthy group. We discourage people from stroke or cardiac investigation if they don’t have risk factors for cardiovascular diseases, such as DM, hypertension, hyperlipidemia and heavy smoking habit.

Sequences
We use standard Siemens sequences for most acquisitions. I would like to deal here particularly with chest screening. We apply black blood HASTE for axial, coronal and sagittal planes in 6 mm slice thickness. It takes only two minutes to capture more than 90 images. While this is adequate for the evaluation of mediastinum because of black blood technique, however, the tissue contrast and resolution is not good enough for the characterization of small lesions. If any suspicious lesion is found, the 3D dynamic study (six seconds for each session and repeated four times) and 3D high resolution images are captured for temporal and spatial information. The delayed enhanced 3D TrueFISP is excellent for the peripheral lung lesion and serves as the supplementary sequence.

Results
Our preliminary results showed that there were 38 cancers detected in 1978 asymptomatic adults [mean age 52 years old] (1.8 %). There were

WHOLE BODY MRI

also another 11.5 % of the clients who required either medical referral due to findings like silent stroke and benign brain tumor, or follow up in the cases of, for example, solitary pulmonary nodule, adrenal adenoma and large ovarian cyst. In our follow up study, we had two false negative cases, both colon cancers, which presented with bloody stool within 3 and 15 months of our screening. There were 5 cancers developed within one-year follow up. Figure 1 The VGH-HT Imaging Center is a joint venture between the 2,800 bed public Veterans General Hospital (VGH) and the private company HealthTech. The hospital provides the accommodation, whilst Dr.Hui-Cheng’s office and HealthTech supply the technology and the specialists. As such, the Center is a shining example of a highly technological yet, at the same time, very humane approach to patient care.

Discussion
The traditional health screening places greater emphasis on the biochemical analysis. The information provided by medical imaging is complementary to functional assessment. There are two approaches proposed, either P.E.T (HIMEDIC center, Yamanashi, Japan) [3], or spiral CT (Mayo Clinic, U.S.A.). However, both approaches involve radiation problems and need to inject radio-isotopes or contrast agents. We propose the use of MRI for whole body survey and US for the supplementary examination of thyroid and abdomen. Both are totally noninvasive and there is no radiation involved. Safety concerns are very important for the health screening, not only for the avoidance of unnecessary radiation but also for intravenous contrast administration. Yasuda reported that cancers were discovered in 67 of 3165 participants (2.1 %) who received comprehensive examinations, including physical examination, laboratory study, ultrasonography, chest CT and whole body PET [3]. P.E.T. findings proved to be positive in 36 of the 67 cases (54 %) (1.2 % of population). The Mayo Clinic study for early lung cancer screening showed fourteen percent of participants had incidental 87

Figure 3 MRI Simulator Dr.Hui-Cheng’s main concern is that patients should feel comfortable at all times. “Opting for whole-body MRI is not only a technological choice but also an ethical one, as there is no radiation involved. We try to provide a relaxed environment from reception through to scanning and finally discharge. We have built an MRI simulator in our preparation room where patients can experience the ‘look and feel’ of the examination: the lighting, sound and, of course, surrounding space.”

Figure 2 The Center is equipped with one Sonata (40 mT/m gradient strength, 200 mT/m/sec slew rate) and a Siemens SONOLINE Elegra ultrasound. There are 3 full-time radiologists, 4 radiographers, 4 nurses and 2 administrators working in the Center.

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Case 1

MCA Aneurysm

Figure 4 Dr. Hui-Cheng

Creativity, comprehensiveness and consideration, the three qualities on which Dr. Hui-Cheng has based his life’s work. He makes use of whole-body MRI and MRA for preventive medicine, offering creative and alternative means of diagnosis. Dr Hui-Cheng is convinced that in the 21st century medical imaging will play an important role in preventive medicine, not least because imaging techniques can detect tumors at an earlier stage compared to alternative methods. New developments, such as the iPAT technique, will help expand the diagnostic limits of Magnetic Resonance Imaging.

MCA Aneurysm

Case 1

MCA Aneurysm

Asymptomatic healthy 48 year old woman. MCA aneurysm was found incidentally during screening.

non-pulmonary findings of clinical importance [4]. Our results were similar in that 11.5 % of participants were referred to clinics. The importance of thyroid US should be emphasized because of high incidence of thyroid cancer in our experience (in 6 of the 38 cancers) and of the low sensitivity of MR in the thyroid gland. There are several blind spots in our cancer screening protocol, such as leukemia, skin cancer and GI tract tumor. Incidentally, our protocol does not include the upper and lower limbs because of few bone malignancies in adults. We had two false negative cases which were colon cancers, one in cecum and the other one in the sigmoid colon. MR colongraphy is planned to be implemented in our screening protocol once we 88

have acquired a new MAGNETOM Sonata. The whole examination took about 60-70 minutes with the Numaris system but it takes less time (50-55 minutes) now under the syngo system, because of the independent reconstruction and data acquisition as well as the faster imaging reconstruction. The 3D shim with new syngo software is also a significant improvement in the imaging quality of breast 3D dynamic study with fat saturation and 3D TrueFISP for Cervical spine. Participants are very positive about our center because we provide solution services, not only to make clear diagnosis but also to provide good clinical back up. Our radiologists always review images during the examination and take additional

sequences, if necessary. We provide 30 minutes interview immediately following the examination for the preliminary oral report. Participants are happy to refer their friends or family to us. We have a long waiting list of up to three months, even without advertising ourselves. At the beginning, our clinical colleagues showed reluctance to our approach because we, as radiologists, made ourselves the first line of contact to our participants as opposed to referral via physicians. Now, they are impressed with what we have achieved and they are happy to accept our referrals because we have done the comprehensive study for them, so that it is almost ready to be managed. They also refer to us patients with unknown primary malignancy or cancer patients with the elevation of tumor markers for examination.

Case 2

Cerebral Embolism

WHOLE BODY MRI

Case 2

Cerebral Embolism

History of stroke over six-month period. The patient was referred to our center to find out the underlying reason. In our stroke program we saw ventricular aneurysm with thrombus. Head and neck MRA was normal. Embolus from a cardiac thrombus seemed to be the reason for the stroke. Anticoagulant was recommended.

Cerebral Embolism

Case 3

Lung Metastasis

Case 3

Lung Metastasis

Lung Metastasis

The patient was operated one year ago due to breast cancer (Stage 2) and she had received chemotherapy. She was accepted in complete remission and sent to our center for cancer detection. In this patient we saw cavitary lesions in the lung (4mm) in both lower lobes. At first, infection was thought to be the reason but in follow-up 4 months and 8 months later, the lesions were found to be growing in size to 8mm and 16 mm with a doubling time of 4 months.

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Case 4

Bronchiectasis

Case 4

Bronchiectasis

Chief complaint of this patient was cough and hemoptysis. We were able to diagnose bronchiectatic changes in the lung with the help of 3D TrueFISP and HASTE sequences.

Bronchiectasis

Case 5

Hepatocellular CA

Case 5

Hepatocellular CA

This patient of 53 years had a history of Hepatitis B and came to our center for “Tumor Detection”. Early arterial enhancing lesion in the liver was seen which led us to the diagnosis of “Hepatocellular cancer”.

Hepatocellular CA

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Case 6

Islet Cell Tumor

This was a 56 year old male patient who came for tumor detection to our center. An unsuspected islet cell tumor (non-functional) was diagnosed.

Case 6

Islet Cell Tumor

Case 7 References:
[ 1 ] Horvath LJ, Burtness BA, McCarthy S, Johnson KM. Total-body echo-planar MR imaging in the staging of breast cancer: comparison with conventional methods-early experience. Radiology 211 (1): 119-28, 1999 [ 2 ] Walker R, Kessar P, Blanchard R. Dimasi M, Harper K, DeCarvalho V, Yucel EK, Patriquin L, Eustace S. TurboSTIR magnetic resonance imaging as a whole-body screening tool for metastases in patients with breast carcinoma: preliminary clinical experience. J Mag Res Imag 11 (4):343-50, 2000. [ 3 ] Yasuda S, Ide M, Fujii H, Nakahara T, Mochizuki Y, Takahashi W, Shohtsu A. Application of positron emission tomography imaging to cancer screening. British J Cancer 83(12): 1607-11, 2000 [ 4 ] Swensen SJ. Screening with low dose spiral CT at the Mayo Clinic: Lung cancer and ancillary findings. RSNA 2001 Syllabus: Categorical Course in Diagnostic Radiology: Thoracic Imaging-Chest and Cardiac, 29-35 91

Ovarian Cancer Metastasis

Case 7

Ovarian Cancer Metastasis

This patient was operated because of ovarian cancer. She was referred to our center for re-staging whole body MRI. A pancreatic lesion was seen which was an unusual place for metastasis. A following distal pancreatectomy proved this lesion to be metastasis.

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Safety Considerations for Patients Referred for Cardiovascular MR Procedures
Frank G. Shellock, Ph.D. Institute for Magnetic Resonance Safety, Education, and Research and Keck School of Medicine University of Southern California Los Angeles, CA, USA MR procedures. Please note that a comprehensive listing of implants, materials, and devices tested for MRsafety or MR-compatibility may be reviewed at www.MRIsafety.com. heart. This includes the Starr-Edwards Model Pre-6000 heart valve prosthesis, which was previously suggested as being a potential hazard for a patient undergoing an MR procedure. If there is a question of a dehisced valve, caution is recommended with regard to exposure to the MR environment.

Aneurysm Clips Introduction
Maintaining a safe magnetic resonance (MR) environment is a daily challenge for radiologists and MRI technologists. The types of biomedical implants and devices that are encountered in patients and individuals entering the MR environment continue to grow. It requires constant attention and diligence to obtain up-to-date information about these objects to provide the safest MR setting possible. In general, patients with implants and devices who undergo MR procedures are at potential risk of dislodgement of the object, induction of electrical currents, excessive heating and misinterpretation of an imaging artifact as an abnormality. Importantly, many reported cases of MR-related injuries have been the result of misinformation about biomedical implants and devices. Recently, there has been an enormous increase in the use of clinical MR techniques for cardiovascular applications, including those used for the assessment of cardiac function and vascular anatomy. Patients referred for these procedures often have implants and devices related to pre-existing conditions that require particular attention from an MR safety consideration. Therefore, this artide will discuss MR safety for a variety of biomedical implants and devices, with an emphasis on those that are commonly encountered in patients referred for cardiovascular 92 There is much controversy and confusion regarding the amount of ferromagnetism that needs to be present in an aneurysm clip to constitute a hazard for a patient in the MR environment. Presently, specific guidelines are recommended for consideration prior to exposing individuals with aneurysm clips to the MR environment (Table 1). There is additional concern that longterm exposures to strong magnetic fields may grossly magnetize aneurysm clips made from nonferromagnetic materials. However, the results of a recent study performed on aneurysm clips made from Elgiloy, Phynox, titanium alloy, pure titanium, and austenitic stainless steel, indicated a lack of clinically significant changes in the magnetic properties of these implants in association with long-term and multiple exposures to 1.5 Tesla MR systems.

PDA, ASD, and VSD Occluders
Various metallic implants used to treat patients with patent ductus arterious conditions (PDA), atrial septal defects (ASD), or ventricular septal defects (VSD) have been tested for MR safety. These devices were made from either 304V stainless steel or MP35N. Patients with cardiac occluders made from MP35N (i.e. a non-ferromagnetic metal) may undergo MR procedures any time after the placement of such devices. Patients with occluders made from 304V stainless steel (i.e. a weakly ferromagnetic metal) are required to wait approximately six to eight weeks after placement to allow for tissue growth to provide additional retentive forces for these implants.

Heart Valve Prostheses and Annuloplasty Rings
The majority of the heart valve prostheses and annuloplasty rings that have been evaluated for magnetic field interactions displayed measurable yet relatively minor attractions to the static magnetic fields of the MR systems used for testing (Fig. 1). Thus, an MR procedure is not considered to be hazardous for a patient one of whose heart valves has undergone testing because the attractive forces exerted on these implants are minimal compared to the force exerted by the beating

Stents, Coils, and Filters
A wide variety of stents (Figs. 2 and 3), filters and coils have been evaluated for MR safety. While most of these implants are made from nonmagnetic metals, others have exhibited magnetic qualities. However, these particular devices typically become securely attached to the vessel wall or tissue site post-operatively in approximately six to eight weeks due to tissue growth or scarring. Notably, an MR examination should not be performed if there is any possibility that the device is not firmly in place or positioned properly within the vessel or tissue.

MRI SAFETY

Coils, stents and filters made from non-ferromagnetic materials (e.g. titanium, titanium alloy, Phynox, Elgiloy, MP35N, 316L stainless steel or Nitinol), are considered safe for patients undergoing MR procedures using MR systems with static magnetic fields up to and including 1.5 Tesla immediately after implantation. If, however, the implant, such as a stent, is made from weakly ferromagnetic material (e.g. certain types of stainless steel), a wait period of six to eight weeks is recommended for tissue ingrowth to help retain it in position during the MR procedure. Note that some manufacturers may not differentiate in their product documentation between their nonferromagnetic devices and those that are weakly ferromagnetic. Obviously, this results in some confusion for the MR safety aspects of these implants. Obtaining documentation that clearly identifies the device and the manufacturer is always recommended. Finally, it is important to remember that new types of stents, coils, and filters continue to be developed which have not undergone MR safety testing. At least two prototype stents have been recently identified that displayed excessive magnetic field interactions, suggesting that not all stents, coils, and filters are safe for individuals in the MR environment.

magnetic field of the MR system; 2. MRI-related heating of the leads by the time-varying fields; 3. inhibition or modification of the function of the pacemaker or ICD by the electromagnetic fields used for MRI, and 4. inappropriate or rapid pacing due to pulsed gradient magnetic fields and/or pulsed radiofrequency (RF) fields (i.e. electromagnetic interference) from the operating MR system, i.e. with the lead acting as an antenna. These problems may result in serious injuries or lethal consequences for patients. Thus, the presence of a cardiac pacemaker is considered a strict contraindication for a patient undergoing an MR procedure using a conventional MR system. There have been at least six fatalities from amongst the at least twelve patients with pacemakers who have been exposed to the MR environment. Deactivation of ICDs can be accomplished by holding a magnet over the device for approximately 30 seconds. Magnetic fields of MR systems would have a similar effect on ICDs, and therefore, patients with these devices should also avoid exposure to the MR environment.

relative contraindication for MR procedures due to the theoretical risk of inducing current that, in turn, could produce arrhythmias in patients. Notably, the study by Hartnell et al. utilized 1.0 and 1.5 Tesla MR systems operating with conventional pulse sequences. Therefore, it would be prudent to use similar MR techniques and parameters as Hartnell et al. for patients with retained cardiac pacing wires until additional investigations are conducted.

MR Procedures and Post-Op Patients
Unfortunately, there is great confusion regarding the issue of performing an MR procedure during the post-op period in a patient with a metallic implant, material, or device. In general, if the metallic object is a “passive implant” (i.e. there is no power associated with the operation of the device) and made from a nonferromagnetic material, e.g. Elgiloy, Phynox, MP35N, titanium, titanium alloy, Nitinol, tantalum, etc., the patient with the object may undergo an MR procedure immediately after placement of the object using an MR system operating at 1.5 Tesla or less. For an object that is “weakly” ferromagnetic, it is typically necessary to wait a period of six to eight weeks prior to performing an MR procedure. In this case, “retentive” or counter forces provided by tissue in growth, scarring or granulation, serve to prevent the object from presenting a hazard to the patient or individual in the MRI environment. It is notable that there has never been a report of an injury to a patient or individual in association with an MRI procedure for the various stents, coils, filters, cardiac occluders, heart valve prostheses, and annuloplasty 93

Retained Cardiac Pacing Wires
A study by Hartnell et al. reported that patients with retained temporary epicardial pacing wires, cut short at the skin (i.e. after they were no longer used post-surgically), did not experience any changes in baseline electrocardiographic rhythms or experience any symptoms during MR procedures. The investigation by Hartnell et al. is of particular importance because the presence of retained pacing wires was previously considered to be a

Cardiac Pacemakers and Implantable Cardioverter Defibrillators
Cardiac pacemakers and implantable cardioverter defibrillators (ICDs) present potential problems to patients undergoing magnetic resonance procedures from several mechanisms, including: 1. movement of the implantable pulse generator and/or leads due to the strong static

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MAGNETOM FLASH 3

rings that have undergone testing. Obviously, if there is any concern regarding the integrity of the tissue with respect to its ability to retain the object in place during an MR procedure or during exposure to the MR environment, the patient or individual should not be permitted near the MR system.

Table 1 Guidelines recommended for consideration prior to exposing individuals with aneurysm clips to the MR environment. [ 1 ] Specific information (i.e. manufacturer, type or model, material, lot and serial numbers) concerning the aneurysm clip must be known, especially with respect to the material used to manufacture it. This information is provided by the manufacturer in the product label for the aneurysm clip. [ 2 ] An aneurysm clip that is in its original package and made from Phynox, Elgiloy, MP35N, titanium alloy, commercially pure titanium or other material known to be non-ferromagnetic or weakly ferromagnetic at 1.5 Tesla or less, does not need to be evaluated for ferromagnetism. [ 3 ] The radiologist and implanting surgeon and radiologist are responsible for evaluating the available information pertaining to the aneurysm clip, verifying its accuracy, obtaining written documentation and deciding whether to perform the MR procedure after considering the risk vs. benefit aspects for a given patient.

Hartnell GG, et al. Safety of MR imaging in patients who have retained metallic materials after cardiac surgery. Am J Roentgenol 1997;168:1157-1159. Sawyer-Glover A, Shellock FG. Pre-MRI procedure screening: recommendations and safety considerations for biomedical implants and devices. Journal of Magnetic Resonance Imaging. 2000;12: 92-106. Shellock FG. Magnetic Resonance Procedures: Health Effects and Safety, CRC Press, LLC, Boca Raton, FL, 2002; www.CRCPress.com Shellock FG. Pocket Guide to MR Procedures and Metallic Objects: Update 2001. Seventh Edition, Lippincott Williams & Wilkins Healthcare, Philadelphia, 2001; www.LWW.com Shellock FG. Reference Manual for Magnetic Resonance Safety: Update 2002. Amirsys, Inc., Salt Lake City, Utah, 2002; www.Amirsys.com Shellock FG, Shellock VJ. Cardiovascular catheters and accessories: Ex vivo testing of ferromagnetism, heating, and artifacts associated with MRI. J Magn Reson Imag 1998;8:1338-1342. Shellock FG, Morisoli SM. Ex vivo evaluation of ferromagnetism, heating, and artifacts for heart valve prostheses exposed to a 1.5-Tesla MR system. J Magn Reson Imaging 1994; 4:756-758. Shellock FG, Morisoli SM. Ex vivo evaluation of ferromagnetism and artifacts for cardiac occluders exposed to a 1.5 Tesla MR system. Journal of Magnetic Resonance Imaging, 1994;4:213-215. Shellock FG, Shellock VJ. Metallic Stents: Evaluation of MR Imaging Safety. AJR American Journal of Roentgenology 1999;173: 543-547. Shellock FG. Prosthetic heart valves and annuloplasty rings: assessment of magnetic field interactions, heating, and artifacts at 1.5-Tesla. Journal of Cardiovascular Magnetic Resonance. 2001;3:159-169.

Web Site for MRI Safety Information
The web site, www.MRIsafety.com, was developed to provide crucial and timely information to healthcare providers and patients seeking answers to questions on MRI safety topics and issues. In addition, the latest information is provided for screening patients with implants, materials and medical devices. The key features of www.MRIsafety.com include: s The List. A searchable database that contains over 900 implants and other objects tested for MR safety. s Safety Information. Useful information that pertains to patient management in the MR environment. s Summary. A presentation and summary of over 100 peer-reviewed articles on MRI bioeffects and safety. s Screening Form. A form for Pre-MRI Screening with free Acrobat software provided to download the form for use by imaging facilities.

Selected References
Ahmed S, Shellock FG. Magnetic resonance imaging safety: implications for cardiovascular patients. Journal of Cardiovascular Magnetic Resonance. 2001;3:171-182. Edwards, M-B, Taylor KM, Shellock FG. Prosthetic heart valves: evaluation of magnetic field interactions, heating, and artifacts at 1.5 Tesla. Journal of Magnetic Resonance Imaging. 2000;12:363-369.

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Figure 1a

Figure 1b Examples of heart valves prostheses (a) and annuloplasty rings (b). Note that all of these implants have metallic components that may impact the MR procedure.

Figure 2 Examples of endovascular stents. These implants have been tested and shown to be safe for patients undergoing MR procedures at 1.5 Tesla or less.

Figure 3 Examples of coronary artery stents. These stents are made from a variety of metallic materials and come in various sizes shapes and sizes.

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of integrating medical technology, IT, management consulting and services. In a way that only Siemens can. Visit SiemensMedical.com/proof. See what we see. Tangible solutions. Proven outcomes.

OPEN CLASS

MAGNETOM Concerto – The economical open MR scanner
Sabine Schaeffer, Ph.D. Market Segment Manager Open Systems Siemens Medical Solutions Erlangen

Performance: Exceptional Image Quality
MAGNETOM Concerto offers superior whole body MR imaging in reasonable acquisition times, thanks to: s very strong gradient performance s high-field computer components s isocenter positioning

MAGNETOM Concerto Open to everyone
The MAGNETOM Concerto is the economical open MR scanner from Siemens. It is a system which guarantees maximum patient acceptance, delivers exceptional image quality and provides an excellent returnon-investment.

s broad sequence selection with high-field applications Our recent software update syngo MR 2002B offers even further improvement to image quality in shorter scan times.

Figure 1 T2 turbo spinecho High image quality also for obese patients due to isocenter positioning.

Patients: Maximum Patient Acceptance
Unrivalled patient comfort! The MAGNETOM Concerto provides maximum comfort for all your patients, boasting the following state-of-the-art features: s C-shaped magnet design s small, inviting appearance s very low gradient noise s reasonable examination times

Profitability: Excellent Return-OnInvestment
The MAGNETOM Concerto is the acknowledged economical choice in the open segment, due to: s high throughput due to optimized workflow s minimal siting requirements s low life-cycle costs Figure 2 T2 TSE Restore T2-weighted images with shorter TR values

At Siemens, we analyze both hardware and software components, continually refining them to optimize your workflow. For proof, look no further than our C-IPA™ coil concept and the Siemens application software syngo. With our newest software update, all our customers can benefit from the new Advanced Workflow Package. It comes as standard with all MAGNETOM Concerto systems and brings Maestro Class benefits to our low-field customers. Figure 3 T2 3D TrueFISP, of small lesions. (e. g. Syrinx in the spinal cord) 2 mm effective slice thickness

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MAGNETOM FLASH 3

Figure 4 T1 3D FLASH, 3D data set covering the entire brain with contigous slias in less than 3 minutes

Figure 5 3D MEDIC, Siemens unique with no flow artefacts

Figure 6 3D DESS, Siemens unique for excellent image

Figure 7 contrast-enhanced MRA of the carotid arteries. Care Bolus + C-IPA™ coil concept allow 300 mm FoV imaging

Figure 8 T1 FLASH breath-hold, Renal Cysts

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New features of MAGNETOM Concerto
Sabine Schaeffer, Ph.D. Market Segment Manager Open Systems Siemens AG Medical Solutions, Erlangen, Germany

The new syngo MR 2002B software offers many improvements. Topics covered in this issue of MAGNETOM Flash are highlighted in bold print.

s workflow optimizations as on high-field  new Protocol Tree format  flexible film formats with Mother-in-Child  Advanced Workflow Package  Siemens unique Inline Technology  Phoenix Figure 1 New syngo user interface

Workflow optimizations as on high-field
s increased range of applications  FLASH 3D Water Excitation  Simultaneous Excitation  Flexible Read-out Matrix  200% Slice Resolution  HASTE Diffusion including ADC maps With our newest software update, all our customers can benefit from the new Advanced Workflow Package. It comes as standard with all MAGNETOM Concerto systems and brings Maestro Class benefits to our low-field customers, including: s Exam Task Card layout with image stamps for a quick overview (Fig. 1) s Online Display for real-time images, which opens automatically s Additional Inline Movie for cine studies s Siemens unique Inline Technology e.g. inline subtraction, inline MIP, inline standard deviation

Increased range of applications
Siemens offers you a wide range of techniques to obtain fat suppressed images. TIRM and Dark Fluid sequences are available for T2/T2*-weighted images. For T1-weigthed images, Siemens now offers you an excellent technique, called Water Excitation. This is a very robust fat suppression technique, which delivers very good fat suppressed T1 images, including post-contrast. The basis for this is a 3D FLASH sequence using an excitation pulse. The separation between fat and water at low-field is only 28 Hz, which means that an advanced technique is necessary.

s substantially improved routine imaging.  new protocols  optimized protocols

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MAGNETOM FLASH 3

2 1
22,5 ° 45 °

1
22,5 °

With 3D FLASH Water Excitation, frequency pulses affect only water protons and leave fat protons almost unexcited (Fig. 2). Ready-to-use protocols were developed for many regions, such as the head, neck, shoulder, elbow, knee and ankle (Fig. 3).

Water

Fat

Figure 2 Water excitation. A 121 (1, 2, 1 at top of image) composite pulse is shown with a total flip angle of 90°. Prior to the first RF pulse (1 at bottom of image), both water (solid arrows) and fat (dashed arrows) hydrogen are unexcited. At the end of the first RF pulse (2 at bottom of image), both are excited 22.5°. Because of the difference in resonant frequencies between fat and water, the fat hydrogen becomes out of phase with the water hydrogen. The time for the second RF pulse (3) is chosen so that the fat hydrogen is exactly 180° out of phase. At the end of the second RF pulse (4), the water proton is rotated 67.5° while the fat hydrogen is rotated -22.5°. A similar delay is chosen between the second and third RF pulses (5). At the end of the third RF pulse (6), the fat hydrogen is at 0° (unexcited), while the water hydrogen is rotated 90°.

1

2

3 time

4

5

6

Figure 3 Head-orbita T1 3D FLASH Water Excitation TR/TE: 34/12, TA 5:50 min, effec. SL: 4 mm, 22 Partitions. Orbital fat suppression

Shoulder T1 3D FLASH Water Excitation TA 5:40 min, eff. SL 3.5 mm, 16 Partitions

Knee T1 3D FLASH Water Excitation TR/TE: 32/11, TA 4:29 min, effec. SL: 4 mm, 28 Partitions 100

Elbow T1 3D FLASH Water Excitation TR/TE: 31/10.3, TA 5:57 min, effec. SL: 3 mm, 256 Matrix, 24 Partitions, FoV of 119 mm

Ankle T1 3D FLASH Water Excitation TR/TE: 31/10.3, TA 4:45 min, effec. SL: 4 mm, 22 Partitions

OPEN CLASS

For optimal excitation of the water protons, you simply need to finetune the system frequency adjustment, beginning with the optimized protocol provided, with different offset sizes, from the protocol tree (Fig. 4) After the measurements, the images are loaded automatically in the Viewing Card. Simply select the best image – the one with dark bone marrow, bright cartilage. Fat and bone marrow should appear darker than muscle tissue. Choose the protocol for diagnosis and adjust the selected offset in the contrast card (Fig. 5).

Figure 4 Select protocols with different offsets

Substantially improved routine imaging
3D imaging guarantees diagnostic confidence with thin, contiguous slice coverage and high contrast, which is the preferred way of scanning at low-field. Siemens provides the most extensive 3D package, tailored for different applications. Our aim is to offer many ready-to-use protocols. Within the new software we have introduced many new protocols and optimized existing ones for your convenience. Figure 5 The measurement parameters can be selected on the Contrast card s 3D CISS for excellent contrast (Fig. 6, Fig. 7) s 3D TrueFISP for high resolution (Fig. 8, Fig. 9) s TSE Restore for shorter scan times (Fig. 10, Fig. 11) s Respiratory triggering for excellent abdominal imaging (Fig. 12)

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Figure 6a Head T2 3D CISS axial TA 3:24 min, effec. SL: 2 mm, 32 Partitions 3D data set in 3 minutes – excellent anatomical details of cranial nerves, Siemens unique

Figure 6b MIP Reconstruction of 3D CISS showing cochlea and semicircular canals

Figure 7a

Figure 7b

T2 3D CISS axial TR/TE: 9.5/4.7, TA 4:10 min, effec. SL: 3 mm, 256 Matrix, 36 Partitions excellent contrast between cord and surrounding cerebro-spinalfluid.

Figure 8 T-spine T2 3D TrueFISP axial TR/TE: 8.6/4.3, TA 3:52 min, effec. SL: 3 mm, 256 Matrix, 40 Partitions 3D dataset in less than 4 minutes

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Figure 9 L-spine T2 3D TrueFISP sag TR/TE: 9/4.5, TA 5 min, effec. SL: 1.5 mm, 256 Matrix, 64 Partitions

Figure 10 T2 TSE Restore cor TR/TE: 2550/109, TA 4:24 min, SL: 5 mm, 256 Matrix, 15 Slices better T2-weighted images with shorter TR values

Figure 11 T2 TSE Restore tra TR/TE: 2550/109, TA 4:14 min, SL: 5 mm, 256 Matrix, 15 Slices

Turbo Spinecho with 3 echos (pd + t2 + t2) and with respiratory triggering

Figure 12 a PD-weighted: TR/TE: 3614.2/58 (pd), TA 7 min, SL: 8 mm, 256 Matrix, 3 x 15 Slices

Figure 12 b T2-weighted: TR/TE: 3614.2/131 (t2), TA 7 min, SL: 8 mm, 256 Matrix, 3 x 15 Slices

Figure 12 c T2-weighted: TR/TE: 3614.2/232 (t2), TA 7 min, SL: 8 mm, 256 Matrix, 3 x 15 Slices

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The information in this document contains general descriptions of the technical options available, which do not always have to be present in individual cases. The required features should therefore be specified in each individual case at the time of closing the contract. Siemens reserves the right to modify the design and specifications contained herein without prior notice. Please contact your local Siemens Sales representative for the most current information. Original images always lose a certain amount of detail when reproduced. This brochure refers to both standard and optional features. Availability and packaging of options varies by country and is subject to change without notice. Some of the features described are not available for commercial distribution in the US.

MAGNETOM Flash – Reader Service
Letters to the Editor – We welcome your comments about the content of MAGNETOM Flash. Please send comments to the Editor. Include your name, address, and phone number or e-mail. World Wide Web – Visit us at www.siemensmedical.com. This site provides information about all Siemens medical products. Publish articles? – You are invited to publish articles in the newsletter to share your experience with MAGNETOM MR users all over the world. To submit an article please contact the Editor. Subscription – You have seen the newsletter and want to get it on a regular basis? In the US, please contact the Applications Helpline (phone 800-888-SIEM) and give us your name and business address (no home addresses, please). Outside the US, MAGNETOM Flash is distributed through the local Siemens offices. Please contact the Editor and we will make sure that you are included on your local support office’s distribution list. Editor Ali Nejat Bengi, M.D, AliNejat.Bengi@siemens.com Published by Siemens AG Medical Solutions P.O.Box 3260, D-91052 Erlangen Correspondence and International Distribution Ali Nejat Bengi, M.D., Editor in Chief MAGNETOM FLASH Siemens AG Medical Solutions, MR Marketing Allee im Röthelheimpark 3 D-91052 Erlangen Phone: 49 - 91 31 - 84 - 75 99 Fax: 49 - 91 31 - 84 - 21 86 US Distribution MR APPLICATIONS HELPLINE Siemens Uptime Service Center 110 MacAlyson Court Cary, NC 27511 Phone: 800 - 888 - SIEM Fax: 919 - 319 - 28 64 Internet: www.siemensmedical.com All articles represent the techniques and opinions of the authors and may not represent specific recommendations or endorsements from Siemens Medical Solutions. Contact the authors directly for further information about their techniques and opinion.

Please contact in the USA: Siemens Medical Solutions USA, Inc. 51 Valley Stream Parkway Malvern, PA 19355 Tel.: 610-448-4500 Fax: 610-448-2254 in Asia: Siemens Advanced Engineering Pte. Ltd. Medical Division Asean Business Centre 2, Kallang Sector Singapore, 349277 (+65) 841 35 28 in Japan: Siemens-Asahi Medical Technologies Ltd. Takanawa Park Tower 14 F 20-14, Higashi-Gotanda 3-chome Shinagawa-ku Tokyo 141-8641 (03) 54 23 40 01 Or contact your local Siemens Sales präsentation Siemens AG, Medical Solutions Magnetic Resonance Henkestr. 127, D-91052 Erlangen, Germany Telephone: ++49 9131 84-0 www.SiemensMedical.com

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